Provider Demographics
NPI:1033249065
Name:CARROLL, PATRICIA ANN (OTRL)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 WOODWINDS DR
Mailing Address - Street 2:#240
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2523
Mailing Address - Country:US
Mailing Address - Phone:651-702-0750
Mailing Address - Fax:
Practice Address - Street 1:2080 WOODWINDS DR
Practice Address - Street 2:#240
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2523
Practice Address - Country:US
Practice Address - Phone:651-702-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100349225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN797605400Medicaid
MN670000068Medicare ID - Type Unspecified