Provider Demographics
NPI:1588982375
Name:CARLSON, CORTNEY RENAE (PT)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:RENAE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:RENAE
Other - Last Name:JOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:32033 SKYRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-7511
Mailing Address - Country:US
Mailing Address - Phone:515-681-4616
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5753
Practice Address - Country:US
Practice Address - Phone:515-699-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA029532251S0007X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA066500Medicaid
IA066500Medicaid