Provider Demographics
NPI:1992715999
Name:CARROLL, MICHAEL KEVIN (PTA, ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28227 JENEVA WAY
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8514
Mailing Address - Country:US
Mailing Address - Phone:239-498-5170
Mailing Address - Fax:
Practice Address - Street 1:9401 FOUNTAIN MEDICAL CT
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4612
Practice Address - Country:US
Practice Address - Phone:239-494-4241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20119225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant