Provider Demographics
NPI:1992976260
Name:PAULSON, CARLENE MARIE (PT)
Entity type:Individual
Prefix:
First Name:CARLENE
Middle Name:MARIE
Last Name:PAULSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-1800
Mailing Address - Country:US
Mailing Address - Phone:701-356-2115
Mailing Address - Fax:
Practice Address - Street 1:330 3RD AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-1800
Practice Address - Country:US
Practice Address - Phone:701-356-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND59796Medicaid