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NPI Code Detail

MEDICARE: MRS. MICHELLE L CARLSON LMT

MEDICARE: MRS. MICHELLE L CARLSON LMT
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
1225700000XMassage Therapist2980-146WI

General Provider Information

NPI Number : 1447659008
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MICHELLE L CARLSON LMT
Provider Business Mailing Address
First Line : 1637 W CLAREWOOD AVE
Second Line :
City : PEORIA
State : IL
Zip : 61614-5736
Country : US
Telephone Number : 309-213-4040
Fax Number :
Provider Business Practice Location Address
First Line : 3322 W WILLOW KNOLLS DR
Second Line : SUITE B
City : PEORIA
State : IL
Zip : 61614-8148
Country : US
Telephone Number : 309-690-3322
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2014
Last Update Date : 08/20/2014

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Directions to “ MRS. MICHELLE L CARLSON LMT” Practice Location

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