Healthcare Provider Details

I. General information

NPI: 1851228035
Provider Name (Legal Business Name): MISTY CARLSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 TULARE ST
FRESNO CA
93721-2266
US

IV. Provider business mailing address

2982 QUINCY AVE
CLOVIS CA
93619-7439
US

V. Phone/Fax

Practice location:
  • Phone: 559-457-3245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number15772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: