Provider Demographics
NPI:1366568289
Name:SANDBERG, CARRIE (PT)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:DUGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4006 ELAINES WAY
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N112W15415 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-3410
Practice Address - Country:US
Practice Address - Phone:262-250-7880
Practice Address - Fax:262-250-7887
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WI10656024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI832070014Medicare PIN
WI000680096Medicare PIN
WI830420021Medicare PIN