Provider Demographics
NPI:1063965507
Name:CARLETON, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CARLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:1772 STIEGER LAKE LANE
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-0034
Mailing Address - Country:US
Mailing Address - Phone:952-443-9888
Mailing Address - Fax:952-443-9804
Practice Address - Street 1:8758 EGAN DR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2561
Practice Address - Country:US
Practice Address - Phone:952-443-9888
Practice Address - Fax:952-443-9804
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103530225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16154051OtherPT CARE
MN169036OtherUCARE
MN565581028803OtherPREFERRED ONE
MN1311578OtherARAZ/AMERICA'S PPO/CIGNA
MN76842OtherHEALTH PARTNERS
MN78B64KIOtherBCBS
MN001442700Medicaid