Provider Demographics
NPI:1013969203
Name:CARLSON, CHERYL LYNN (PT)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:CHERYL
Other - Middle Name:LYNN
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:W3101 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:VULCAN
Mailing Address - State:MI
Mailing Address - Zip Code:49892-8290
Mailing Address - Country:US
Mailing Address - Phone:906-563-8204
Mailing Address - Fax:906-563-8942
Practice Address - Street 1:W3101 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:VULCAN
Practice Address - State:MI
Practice Address - Zip Code:49892-8290
Practice Address - Country:US
Practice Address - Phone:906-563-8204
Practice Address - Fax:906-563-8942
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6284-024208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650B210380OtherBLUE CROSS
MI650B210460OtherBCBS
MIP00315590Medicare PIN
MIMII0693001Medicare Oscar/Certification
MI650B210460OtherBCBS
MIP33380001Medicare PIN