Provider Demographics
NPI:1528467131
Name:TEWALT, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TEWALT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16410 HIGHWAY 126
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-9599
Mailing Address - Country:US
Mailing Address - Phone:971-302-5479
Mailing Address - Fax:
Practice Address - Street 1:16410 HIGHWAY 126
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-9599
Practice Address - Country:US
Practice Address - Phone:971-302-5479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16516225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist