Healthcare Provider Details

I. General information

NPI: 1750750014
Provider Name (Legal Business Name): CARRIE POWELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 EULAINE CIR
HAMMOND WI
54015-5033
US

IV. Provider business mailing address

981 EULAINE CIR
HAMMOND WI
54015-5033
US

V. Phone/Fax

Practice location:
  • Phone: 651-295-8285
  • Fax:
Mailing address:
  • Phone: 651-295-8285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA629
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: