Provider Demographics
NPI:1588134670
Name:CARLSON, SHELBY LINNEA
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LINNEA
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 1:2862 ROUTE 62
Mailing Address - Street 2:
Mailing Address - City:KENNEDY
Mailing Address - State:NY
Mailing Address - Zip Code:14747-9518
Mailing Address - Country:US
Mailing Address - Phone:716-969-7751
Mailing Address - Fax:
Practice Address - Street 1:11075 W CENTER STREET EXT
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-9557
Practice Address - Country:US
Practice Address - Phone:585-798-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009096-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant