Provider Demographics
NPI:1790003515
Name:CARLSON, ROBERT SHAUN (MPT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:SHAUN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 BRYNN MARR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-478-9701
Mailing Address - Fax:910-478-9703
Practice Address - Street 1:884 LOBLOLLY DR
Practice Address - Street 2:
Practice Address - City:VASS
Practice Address - State:NC
Practice Address - Zip Code:28396
Practice Address - Country:US
Practice Address - Phone:910-478-9701
Practice Address - Fax:910-478-9703
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist