Provider Demographics
NPI:1962853465
Name:CARLSON, CODY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HALTON RD
Mailing Address - Street 2:APT 14305
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3440
Mailing Address - Country:US
Mailing Address - Phone:706-264-0670
Mailing Address - Fax:
Practice Address - Street 1:11 E AUGUSTA PL
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-1755
Practice Address - Country:US
Practice Address - Phone:864-916-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC.8242 PT225100000X
GAPT012367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist