Provider Demographics
NPI:1205967130
Name:CARLSON-WILSON, LUCINDA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:LUCINDA
Middle Name:MARIE
Last Name:CARLSON-WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:MARIE
Other - Last Name:CARLSON-WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:111 W 3RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-2321
Mailing Address - Country:US
Mailing Address - Phone:471-782-0844
Mailing Address - Fax:
Practice Address - Street 1:111 W 3RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2321
Practice Address - Country:US
Practice Address - Phone:471-782-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004009851225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist