Provider Demographics
NPI:1033224696
Name:DWIGHT, CAROLYN L (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:L
Last Name:DWIGHT
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 1:1700 E BOGARD RD BLDG B
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6563
Mailing Address - Country:US
Mailing Address - Phone:907-376-4325
Mailing Address - Fax:
Practice Address - Street 1:1700 E BOGARD RD BLDG B
Practice Address - Street 2:SUITE 203
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6563
Practice Address - Country:US
Practice Address - Phone:907-376-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK64225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT1806Medicaid
AKPT18061Medicaid
AKPT18061Medicaid
AKK160595Medicare PIN