Provider Demographics
NPI:1043723521
Name:BENDER, CARRIE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:NICOLE
Last Name:BENDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 AMHURST RD
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-8840
Mailing Address - Country:US
Mailing Address - Phone:608-436-1720
Mailing Address - Fax:
Practice Address - Street 1:2121 PIONEER DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3025
Practice Address - Country:US
Practice Address - Phone:608-365-9526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2611-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant