Provider Demographics
NPI:1639970080
Name:CARLSON, MIA LEIGH
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:LEIGH
Last Name:CARLSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GRAND AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-6300
Mailing Address - Country:US
Mailing Address - Phone:908-809-9204
Mailing Address - Fax:
Practice Address - Street 1:300 GRAND AVE STE 201
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-6300
Practice Address - Country:US
Practice Address - Phone:201-608-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program