Provider Demographics
NPI:1821063017
Name:CARLSON, LYNETTE MAE (DHS, ATC)
Entity Type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:MAE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DHS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 STRINGERS RIDGE RD APT 2K
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-3238
Mailing Address - Country:US
Mailing Address - Phone:630-674-2584
Mailing Address - Fax:
Practice Address - Street 1:635 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5603
Practice Address - Country:US
Practice Address - Phone:630-455-6630
Practice Address - Fax:630-455-6631
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0020402255A2300X
TN5282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty