Provider Demographics
NPI:1316671266
Name:CARLSON, ADASIAH
Entity type:Individual
Prefix:
First Name:ADASIAH
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 1:13851 W LA MAR BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1389
Mailing Address - Country:US
Mailing Address - Phone:623-399-6159
Mailing Address - Fax:623-399-6416
Practice Address - Street 1:13851 W LA MAR BLVD STE D
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1389
Practice Address - Country:US
Practice Address - Phone:623-399-6159
Practice Address - Fax:623-399-6416
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008876225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist