Provider Demographics
NPI:1932314325
Name:CARLSON, CONSTANCE LYNN (LMP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:4121 DAYTON AVE N
Mailing Address - Street 2:#101
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7745
Mailing Address - Country:US
Mailing Address - Phone:206-518-1623
Mailing Address - Fax:
Practice Address - Street 1:600 N 36TH ST STE 319
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8698
Practice Address - Country:US
Practice Address - Phone:206-518-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017684172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA0017684OtherLICENSE, MASSAGE PRACTIT.