MEDICARE: CONSTANCE LYNN CARLSON LMP

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	172M00000X	Mechanotherapist	MA00017684	WA
2	225700000X	Massage Therapist	MA00017684	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA0017684	OTHER	WA	LICENSE, MASSAGE PRACTIT.

General Provider Information

NPI Number	:	1932314325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSTANCE LYNN CARLSON LMP

Provider Business Mailing Address
First Line	:	4121 DAYTON AVE N
Second Line	:	#101
City	:	SEATTLE
State	:	WA
Zip	:	98103-7745
Country	:	US
Telephone Number	:	206-518-1623
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 N 36TH ST STE 319
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8698
Country	:	US
Telephone Number	:	206-518-1623
Fax Number	:

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

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	08/05/2009

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