Provider Demographics
NPI:1780984526
Name:CARLSON, KRYSTAL LEE (OTR/L)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 S MACON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4433
Mailing Address - Country:US
Mailing Address - Phone:540-589-7979
Mailing Address - Fax:
Practice Address - Street 1:719 S MACON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4433
Practice Address - Country:US
Practice Address - Phone:540-589-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119004077OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONALS
MDC-642-478-497-159OtherMD DRIVER'S LICENSE