Provider Demographics
NPI:1881105757
Name:CARLSON, ELISE (ATC/LAT, MS)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:ATC/LAT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-2909
Mailing Address - Country:US
Mailing Address - Phone:914-708-8980
Mailing Address - Fax:
Practice Address - Street 1:3313 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-9423
Practice Address - Country:US
Practice Address - Phone:954-571-9500
Practice Address - Fax:561-955-2574
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL27592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer