Provider Demographics
NPI:1174146948
Name:CARLSON, SHELLY R (QMHA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3723 FAIRVIEW INDUSTRIAL DR SE STE 170
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1174
Mailing Address - Country:US
Mailing Address - Phone:503-371-1970
Mailing Address - Fax:503-371-0192
Practice Address - Street 1:3723 FAIRVIEW INDUSTRIAL DR SE STE 170
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1174
Practice Address - Country:US
Practice Address - Phone:503-371-1970
Practice Address - Fax:503-371-0192
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner