Provider Demographics
NPI:1023586682
Name:CARLSON, MICHELE ELISABETH
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ELISABETH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:ELISABETH
Other - Last Name:SERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5910 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4704
Mailing Address - Country:US
Mailing Address - Phone:209-475-1000
Mailing Address - Fax:
Practice Address - Street 1:5910 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4704
Practice Address - Country:US
Practice Address - Phone:209-475-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist