Provider Demographics
NPI:1538627674
Name:CARLSON, DANIELLE ILEANA (PTA)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ILEANA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:ILEANA
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3704 SAINT ANDREWS PL
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-3848
Mailing Address - Country:US
Mailing Address - Phone:904-607-9518
Mailing Address - Fax:
Practice Address - Street 1:23770 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9644
Practice Address - Country:US
Practice Address - Phone:269-445-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005675A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant