Provider Demographics
NPI:1659923654
Name:CARLSON, RENEE BETH
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:BETH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1801
Mailing Address - Country:US
Mailing Address - Phone:563-382-6212
Mailing Address - Fax:563-382-6420
Practice Address - Street 1:111 E WATER ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-1801
Practice Address - Country:US
Practice Address - Phone:563-382-6212
Practice Address - Fax:563-382-6420
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224900000X
IA224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter