Provider Demographics
NPI:1093045155
Name:CARROLL, REBECCA MAE GOAL (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MAE GOAL
Last Name:CARROLL
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 1:5823 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3084
Mailing Address - Country:US
Mailing Address - Phone:315-418-4013
Mailing Address - Fax:315-478-0388
Practice Address - Street 1:5417 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031
Practice Address - Country:US
Practice Address - Phone:315-418-4043
Practice Address - Fax:315-469-1324
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA0172OtherMCR GROUP
NY02052091OtherMEDICAID GRP
AA0171OtherMCR GROUP
NYPENDINGMedicaid
1710923222OtherGRP NPI
AA0171OtherMCR GROUP