Provider Demographics
NPI:1821426867
Name:MATHIESEN, CARRIE LYNE M (DPT)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE LYNE
Middle Name:M
Last Name:MATHIESEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19N050 WOODVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-8314
Mailing Address - Country:US
Mailing Address - Phone:847-293-9013
Mailing Address - Fax:
Practice Address - Street 1:2375 TELSTAR DR STE 115
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1029
Practice Address - Country:US
Practice Address - Phone:719-282-2320
Practice Address - Fax:719-282-2330
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.020366208100000X
COPTL.0012475208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation