Provider Demographics
NPI:1154440766
Name:CARROLL, ANGELA (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CARROLL
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 1:9119 SHADOW GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-6602
Mailing Address - Country:US
Mailing Address - Phone:239-225-9125
Mailing Address - Fax:239-225-9127
Practice Address - Street 1:9119 SHADOW GLEN WAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-6602
Practice Address - Country:US
Practice Address - Phone:239-225-9125
Practice Address - Fax:239-225-9127
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 19917225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant