=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619482593
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA CARPENTER PTA, LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 517 E NORTH ST
-----------------------------------------------------
City | BRADLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60915-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-802-7503
-----------------------------------------------------
Fax | 815-802-7514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 517 E NORTH ST
-----------------------------------------------------
City | BRADLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60915-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-802-7503
-----------------------------------------------------
Fax | 815-802-7514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227008895
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 160.007954
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------