MEDICARE: CAROLYN MUSHOLT PT

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	225100000X	Physical Therapist	070005018	IL
2	225100000X	Physical Therapist	2006005286	MO

General Provider Information

NPI Number	:	1316267719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN MUSHOLT PT

Provider Business Mailing Address
First Line	:	4700 PEBBLE BEACH DR
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-6098
Country	:	US
Telephone Number	:	847-404-3854
Fax Number	:	217-228-2262

Provider Business Practice Location Address
First Line	:	4700 PEBBLE BEACH DR
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-6098
Country	:	US
Telephone Number	:	847-404-3854
Fax Number	:	217-228-2262

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

Provider Enumeration Date	:	06/08/2010
Last Update Date	:	05/08/2012

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Directions to “ CAROLYN MUSHOLT PT” Practice Location

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