Provider Demographics
NPI:1891298527
Name:WHARTON, CAROLYN JANE (CMT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JANE
Last Name:WHARTON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 COACHMAN RD STE 214
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1800
Mailing Address - Country:US
Mailing Address - Phone:651-452-4220
Mailing Address - Fax:651-452-3829
Practice Address - Street 1:3390 COACHMAN RD STE 214
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1800
Practice Address - Country:US
Practice Address - Phone:651-452-4220
Practice Address - Fax:651-452-3829
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist