Provider Demographics
NPI:1538773866
Name:KOLBENSCHLAG, CARSON
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:KOLBENSCHLAG
Suffix:
Gender:M
Credentials:
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 33932
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-3932
Mailing Address - Country:US
Mailing Address - Phone:318-813-2970
Mailing Address - Fax:318-813-2975
Practice Address - Street 1:1450 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4204
Practice Address - Country:US
Practice Address - Phone:318-813-2970
Practice Address - Fax:318-813-2981
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10462R225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid