Healthcare Provider Details

I. General information

NPI: 1760630313
Provider Name (Legal Business Name): CARRIE SHORTRIDGE PTA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 STATE ROAD 32 E
WESTFIELD IN
46074-8767
US

IV. Provider business mailing address

PO BOX 358
TIPTON IN
46072-0358
US

V. Phone/Fax

Practice location:
  • Phone: 877-366-2663
  • Fax: 317-867-7701
Mailing address:
  • Phone: 765-675-8119
  • Fax: 765-675-8257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001754A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000474A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: