Provider Demographics
NPI:1215274980
Name:CARROLL, ADAM (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603B N FAIR ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-3906
Mailing Address - Country:US
Mailing Address - Phone:573-366-7020
Mailing Address - Fax:
Practice Address - Street 1:15024 LYONS ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3958
Practice Address - Country:US
Practice Address - Phone:573-366-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist