Basic Information
| Provider Information | |||||||||
| NPI: | 1821063017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | LYNETTE | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DHS, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1131 STRINGERS RIDGE RD APT 2K | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374053238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306742584 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304556630 | ||||||||
| FaxNumber: | 6304556631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 08/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 096.002040 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 528 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.