Provider Demographics
NPI:1427288356
Name:LAUSEN, CARLIE M (DPT)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:M
Last Name:LAUSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CARLIE
Other - Middle Name:M
Other - Last Name:LAUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:12072 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2462
Mailing Address - Country:US
Mailing Address - Phone:208-939-0533
Mailing Address - Fax:208-939-3341
Practice Address - Street 1:13895 W WAINWRIGHT DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5011
Practice Address - Country:US
Practice Address - Phone:208-939-0533
Practice Address - Fax:208-939-3341
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652820Medicare PIN