Provider Demographics
NPI:1710051388
Name:CARLSON, MICHAEL LLOYD (RPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LLOYD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18821 DELAWARE ST
Mailing Address - Street 2:SUITE # 103
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1926
Mailing Address - Country:US
Mailing Address - Phone:714-596-9799
Mailing Address - Fax:714-596-9739
Practice Address - Street 1:18821 DELAWARE ST
Practice Address - Street 2:SUITE # 103
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1926
Practice Address - Country:US
Practice Address - Phone:714-596-9799
Practice Address - Fax:714-596-9739
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT5756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001460Medicaid
PT5756Medicare ID - Type Unspecified