Provider Demographics
NPI:1982978672
Name:CARLSON, MATTHEW HERRICK (ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HERRICK
Last Name:CARLSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 15TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0130
Mailing Address - Country:US
Mailing Address - Phone:612-625-6864
Mailing Address - Fax:612-626-4789
Practice Address - Street 1:516 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0130
Practice Address - Country:US
Practice Address - Phone:612-625-6864
Practice Address - Fax:612-626-4789
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer