Provider Demographics
NPI:1306283049
Name:CARLSON, TONYA
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:CARLSON
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 1:7841 N HOLYOKE LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-4980
Mailing Address - Country:US
Mailing Address - Phone:208-660-2183
Mailing Address - Fax:
Practice Address - Street 1:7841 N HOLYOKE LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-4980
Practice Address - Country:US
Practice Address - Phone:208-660-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-79225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist