Provider Demographics
NPI:1912379686
Name:CARSON, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13079 RACHO SCHOOL DR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4755
Mailing Address - Country:US
Mailing Address - Phone:313-576-6999
Mailing Address - Fax:
Practice Address - Street 1:13079 RACHO SCHOOL DR
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4755
Practice Address - Country:US
Practice Address - Phone:313-576-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker