MEDICARE: COREY CARLSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	7401	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417244310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY CARLSON OTR/L

Provider Business Mailing Address
First Line	:	1105 BITTERSWEET CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-3661
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3325 EXECUTIVE DR STE 222
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-7449
Country	:	US
Telephone Number	:	919-954-3492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	06/30/2011

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