MEDICARE: LAURA CARPENTER PTA, LMT

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	225700000X	Massage Therapist	227008895	IL
2	225200000X	Physical Therapy Assistant	160.007954	IL

General Provider Information

NPI Number	:	1619482593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA CARPENTER PTA, LMT

Provider Business Mailing Address
First Line	:	517 E NORTH ST
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1258
Country	:	US
Telephone Number	:	815-802-7503
Fax Number	:	815-802-7514

Provider Business Practice Location Address
First Line	:	517 E NORTH ST
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1258
Country	:	US
Telephone Number	:	815-802-7503
Fax Number	:	815-802-7514

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

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	03/17/2018

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