=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538416011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN MICHELLE CARLSON DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2012
-----------------------------------------------------
Last Update Date | 09/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13365 OVERSEAS HWY SUITE 103
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-289-0707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 SOMBRERO BEACH RD APT 303
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-269-2163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070019342
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------