Healthcare Provider Details

I. General information

NPI: 1972864361
Provider Name (Legal Business Name): MS. LAEL IRENE CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2012
Last Update Date: 06/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GRAND AVE
OAKLAND CA
94612-3781
US

IV. Provider business mailing address

104 OLIVE AVE
PIEDMONT CA
94611-4430
US

V. Phone/Fax

Practice location:
  • Phone: 510-835-2131
  • Fax:
Mailing address:
  • Phone: 510-919-1063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: