Provider Demographics
NPI:1922125251
Name:CARLSON, TERESA KNEELAND (PT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:KNEELAND
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:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-0816
Mailing Address - Country:US
Mailing Address - Phone:360-482-2774
Mailing Address - Fax:
Practice Address - Street 1:575 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9551
Practice Address - Country:US
Practice Address - Phone:360-482-5640
Practice Address - Fax:360-482-5132
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7092307Medicaid
WA7092307Medicaid