Healthcare Provider Details

I. General information

NPI: 1336646819
Provider Name (Legal Business Name): ELENITA MANDILAG CARLSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 ELECTRIC AVE
SPRINGDALE AR
72764-7498
US

IV. Provider business mailing address

5633 E GI GI CIR
FAYETTEVILLE AR
72703-6433
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-1500
  • Fax:
Mailing address:
  • Phone: 973-960-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4617
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: