Provider Demographics
NPI:1003985995
Name:SELF, CARRIE E (PT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:E
Last Name:SELF
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 1:873 C EVA ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-1808
Mailing Address - Country:US
Mailing Address - Phone:936-597-5323
Mailing Address - Fax:936-597-8914
Practice Address - Street 1:873 C EVA ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-1808
Practice Address - Country:US
Practice Address - Phone:936-597-5323
Practice Address - Fax:936-597-8914
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11204342251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic