Provider Demographics
NPI:1457395964
Name:CARLSON, RICHARD E (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OLD ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:31 OLD ROUTE 7
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-1714
Practice Address - Country:US
Practice Address - Phone:203-740-0020
Practice Address - Fax:203-740-7354
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V8093OtherHEALTHNET
CT004210126Medicaid
CT080001940CTOtherANTHEM BC
CT650000185Medicare ID - Type Unspecified