Provider Demographics
NPI:1669846580
Name:CARLSON, MELISSA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-0546
Mailing Address - Country:US
Mailing Address - Phone:541-944-5203
Mailing Address - Fax:
Practice Address - Street 1:714 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6712
Practice Address - Country:US
Practice Address - Phone:541-944-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21585225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist