Provider Demographics
NPI:1629222799
Name:CARLSON, CONSTANCE E (PT)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10758 MOLONY RD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5449
Mailing Address - Country:US
Mailing Address - Phone:310-839-2155
Mailing Address - Fax:
Practice Address - Street 1:6133 BRISTOL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6609
Practice Address - Country:US
Practice Address - Phone:310-337-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-15
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 13019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist