Provider Demographics
NPI:1114982550
Name:MENTELE, CARRIE A (DPT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:MENTELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:HOWARD
Mailing Address - State:SD
Mailing Address - Zip Code:57349-0039
Mailing Address - Country:US
Mailing Address - Phone:605-772-2131
Mailing Address - Fax:605-772-2041
Practice Address - Street 1:131 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOWARD
Practice Address - State:SD
Practice Address - Zip Code:57349
Practice Address - Country:US
Practice Address - Phone:605-772-2131
Practice Address - Fax:605-772-2041
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1240225100000X
SD1025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54130Medicaid
SD5832872Medicaid
SD101120Medicare PIN
ND22262Medicare PIN
ND54130Medicaid