Provider Demographics
NPI:1306292008
Name:CARSON, RANDY LEE (REHAB THERAPIST)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:CARSON
Suffix:
Gender:M
Credentials:REHAB THERAPIST
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 7321
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77508-7321
Mailing Address - Country:US
Mailing Address - Phone:832-368-4010
Mailing Address - Fax:
Practice Address - Street 1:11911 JONES RD STE 7
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-5232
Practice Address - Country:US
Practice Address - Phone:832-368-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02242001225400000X
TXMT032379225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist