Provider Demographics
NPI:1750454575
Name:CARSON, REBECCA (LMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CARSON
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 1:1115 MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2745
Mailing Address - Country:US
Mailing Address - Phone:850-624-2353
Mailing Address - Fax:
Practice Address - Street 1:11212 FRONT BEACH RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3668
Practice Address - Country:US
Practice Address - Phone:850-624-2353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA34787225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1723OtherBLUE CROSS PROVIDER