Provider Demographics
NPI:1306126115
Name:CARROLL, AMY (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1277
Mailing Address - Country:US
Mailing Address - Phone:815-877-8061
Mailing Address - Fax:
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1820-19225200000X
IL160005984225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant