Provider Demographics
NPI:1427654789
Name:CARLSON, MCKINZEY WICKEL (DPT)
Entity type:Individual
Prefix:
First Name:MCKINZEY
Middle Name:WICKEL
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W 600 S STE 200
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-2284
Mailing Address - Country:US
Mailing Address - Phone:435-654-5607
Mailing Address - Fax:435-654-2602
Practice Address - Street 1:345 W 600 S STE 200
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2284
Practice Address - Country:US
Practice Address - Phone:435-654-5607
Practice Address - Fax:435-654-2602
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11808950-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist