1568786739 NPI number — MS. KELLEY RENEA CARLSON MPT, OMPT

Table of content: MS. KELLEY RENEA CARLSON MPT, OMPT (NPI 1568786739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568786739 NPI number — MS. KELLEY RENEA CARLSON MPT, OMPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
KELLEY
Provider Middle Name:
RENEA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MPT, OMPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568786739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W END AVE
Provider Second Line Business Mailing Address:
APT 23D
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10023-6349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-709-5490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 W END AVE
Provider Second Line Business Practice Location Address:
APT 23D
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10023-6349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-709-5490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2010

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: 225100000X , with the licence number:  62030102 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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