Provider Demographics
NPI:1033692876
Name:CARROLL, MINDI RAY (PTA)
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:RAY
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MINDI
Other - Middle Name:RAY
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0212
Mailing Address - Country:US
Mailing Address - Phone:210-844-1906
Mailing Address - Fax:
Practice Address - Street 1:3002 AVENUE Q
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-3422
Practice Address - Country:US
Practice Address - Phone:830-426-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2097212225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant