Provider Demographics
NPI:1730476300
Name:CARLSON, MARY (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3023 BUNKER HILL ST
Mailing Address - Street 2:#201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5706
Mailing Address - Country:US
Mailing Address - Phone:619-977-6491
Mailing Address - Fax:
Practice Address - Street 1:3023 BUNKER HILL ST
Practice Address - Street 2:#201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5706
Practice Address - Country:US
Practice Address - Phone:619-977-6491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5790172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist