Provider Demographics
NPI:1982690467
Name:KARLSON, TRACEE JEAN MARTIN
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:JEAN MARTIN
Last Name:KARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEE
Other - Middle Name:J
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6028 TIGER TAIL DR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-2141
Mailing Address - Country:US
Mailing Address - Phone:360-584-4556
Mailing Address - Fax:360-251-0011
Practice Address - Street 1:1802 BLACK LAKE BLVD SW STE 103
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5634
Practice Address - Country:US
Practice Address - Phone:360-584-4556
Practice Address - Fax:360-251-0011
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0177730OtherLABOR AND INDUSTRIES
WA0177730OtherLABOR AND INDUSTRIES
WAG8800744Medicare PIN
WA0177730OtherLABOR AND INDUSTRIES