Healthcare Provider Details

I. General information

NPI: 1669951224
Provider Name (Legal Business Name): KATELYN CARSON CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 CALDWELL DR
SOQUEL CA
95073-2055
US

IV. Provider business mailing address

2248 CAPITOLA RD APT D
SANTA CRUZ CA
95062-3143
US

V. Phone/Fax

Practice location:
  • Phone: 831-576-3000
  • Fax:
Mailing address:
  • Phone: 530-575-2791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: