Provider Demographics
NPI:1871822320
Name:CARLSON, LYNETTE RENE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:RENE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 CHESTER PARK
Mailing Address - Street 2:31 WEST COLLEGE STREET
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-3010
Mailing Address - Country:US
Mailing Address - Phone:218-726-6151
Mailing Address - Fax:218-726-8693
Practice Address - Street 1:31 W COLLEGE ST
Practice Address - Street 2:174 CHESTER PARK
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1106
Practice Address - Country:US
Practice Address - Phone:218-726-6151
Practice Address - Fax:218-726-8693
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist