MEDICARE: WANDA CARROLL PTA, LMT, CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	M00487	MD
2	225700000X	Massage Therapist	M00487	MD
3	225200000X	Physical Therapy Assistant	A3443	MD
4	374U00000X	Home Health Aide	A00010416	MD
5	376K00000X	Nurse's Aide	A00010416	MD

General Provider Information

NPI Number	:	1356566731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA CARROLL PTA, LMT, CNA

Provider Business Mailing Address
First Line	:	839 COTTONWOOD DR
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-2836
Country	:	US
Telephone Number	:	443-986-2959
Fax Number	:

Provider Business Practice Location Address
First Line	:	839 COTTONWOOD DR
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-2836
Country	:	US
Telephone Number	:	443-986-2959
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	06/09/2015

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