Healthcare Provider Details

I. General information

NPI: 1851401475
Provider Name (Legal Business Name): TRACI MARIE CARLSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI MARIE KOENIG P.T.

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 COMMERCE RD
ANNAPOLIS MD
21401-2944
US

IV. Provider business mailing address

1709 REMINGTON DR
CROFTON MD
21114-1844
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-2626
  • Fax: 410-224-0512
Mailing address:
  • Phone: 301-261-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19580
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: