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NPI Code Detail

MEDICARE: DANIELLE ILEANA CARLSON PTA

MEDICARE: DANIELLE ILEANA CARLSON PTA
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
1225200000XPhysical Therapy Assistant06005675AIN

General Provider Information

NPI Number : 1538627674
Entity Type Code : Individual
Provider Name (Legal Business Name) : DANIELLE ILEANA CARLSON PTA
Provider Business Mailing Address
First Line : 3704 SAINT ANDREWS PL
Second Line :
City : ELKHART
State : IN
Zip : 46517-3848
Country : US
Telephone Number : 904-607-9518
Fax Number :
Provider Business Practice Location Address
First Line : 23770 HOSPITAL ST
Second Line :
City : CASSOPOLIS
State : MI
Zip : 49031-9644
Country : US
Telephone Number : 269-445-3801
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/07/2019
Last Update Date : 03/07/2019

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