Provider Demographics
NPI:1720352156
Name:CARSON, TERESEA JOANN (LMP)
Entity Type:Individual
Prefix:
First Name:TERESEA
Middle Name:JOANN
Last Name:CARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-3403
Mailing Address - Country:US
Mailing Address - Phone:360-575-9311
Mailing Address - Fax:
Practice Address - Street 1:207 ALLEN ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-3403
Practice Address - Country:US
Practice Address - Phone:360-575-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist