Provider Demographics
NPI:1982292892
Name:CARLSON, SHAYNA
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2276 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36413 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3839
Practice Address - Country:US
Practice Address - Phone:734-331-9087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006267225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty