Provider Demographics
NPI:1811223027
Name:CARLSON, MARY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 SEVEN LOCKS RD
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3260
Mailing Address - Country:US
Mailing Address - Phone:301-983-1390
Mailing Address - Fax:301-983-1498
Practice Address - Street 1:11215 SEVEN LOCKS RD
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3260
Practice Address - Country:US
Practice Address - Phone:301-983-1390
Practice Address - Fax:301-983-1498
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD20508OtherPT LICENSE