MEDICARE: MISTY DAWN MICHELLE CARLSON LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00014648	WA

General Provider Information

NPI Number	:	1043368228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY DAWN MICHELLE CARLSON LMP

Provider Business Mailing Address
First Line	:	1200 HARRIS AVE STE 402
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-7146
Country	:	US
Telephone Number	:	360-319-4929
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 HARRIS AVE STE 402
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-7146
Country	:	US
Telephone Number	:	360-319-4929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	01/16/2018

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