MEDICARE: SHELBY LINNEA CARLSON

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	225200000X	Physical Therapy Assistant	009096-1	NY

General Provider Information

NPI Number	:	1588134670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY LINNEA CARLSON

Provider Business Mailing Address
First Line	:	2862 ROUTE 62
Second Line	:
City	:	KENNEDY
State	:	NY
Zip	:	14747-9518
Country	:	US
Telephone Number	:	716-969-7751
Fax Number	:

Provider Business Practice Location Address
First Line	:	11075 W CENTER STREET EXT
Second Line	:
City	:	MEDINA
State	:	NY
Zip	:	14103-9557
Country	:	US
Telephone Number	:	585-798-1053
Fax Number	:

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

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	11/30/2018

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Directions to “ SHELBY LINNEA CARLSON ” Practice Location

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