Provider Demographics
NPI:1316267719
Name:MUSHOLT, CAROLYN (PT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MUSHOLT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6098
Mailing Address - Country:US
Mailing Address - Phone:847-404-3854
Mailing Address - Fax:217-228-2262
Practice Address - Street 1:4700 PEBBLE BEACH DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-6098
Practice Address - Country:US
Practice Address - Phone:847-404-3854
Practice Address - Fax:217-228-2262
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005018225100000X
MO2006005286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist