1205967130 NPI number — LUCINDA MARIE CARLSON-WILSON LMT

Table of content: LUCINDA MARIE CARLSON-WILSON LMT (NPI 1205967130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205967130 NPI number — LUCINDA MARIE CARLSON-WILSON LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON-WILSON
Provider First Name:
LUCINDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARLSON-WILSON
Provider Other First Name:
CINDY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1205967130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 W 3RD ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64801-2321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
471-782-0844
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 W 3RD ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64801-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
471-782-0844
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  2004009851 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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