Provider Demographics
NPI:1134113111
Name:SKINNER-SANDORA, CAROLYN RAE (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RAE
Last Name:SKINNER-SANDORA
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 1:3273 RIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-7149
Mailing Address - Country:US
Mailing Address - Phone:954-326-0128
Mailing Address - Fax:
Practice Address - Street 1:12341 NW 18TH ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33323-2122
Practice Address - Country:US
Practice Address - Phone:954-478-4648
Practice Address - Fax:954-530-5694
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7183AMedicare ID - Type Unspecified