Provider Demographics
NPI:1265997951
Name:CARLSON, COREY KATHELEEN (ATC)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:KATHELEEN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 HERDMAN HILL RD
Mailing Address - Street 2:
Mailing Address - City:LURAY
Mailing Address - State:VA
Mailing Address - Zip Code:22835-7133
Mailing Address - Country:US
Mailing Address - Phone:540-631-1648
Mailing Address - Fax:
Practice Address - Street 1:184 PANTHER DR
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:VA
Practice Address - Zip Code:22849-3022
Practice Address - Country:US
Practice Address - Phone:540-652-8712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1260021852083S0010X
VA01260021852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine