Provider Demographics
NPI:1215030267
Name:SANDRIDGE, CAROLYN ELAINE (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:ELAINE
Last Name:SANDRIDGE
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 1:2195 CHEAT RD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508
Mailing Address - Country:US
Mailing Address - Phone:304-594-2500
Mailing Address - Fax:304-594-9310
Practice Address - Street 1:2195 CHEAT RD.
Practice Address - Street 2:SUITE 1
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:304-594-2500
Practice Address - Fax:304-594-9310
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302130000Medicaid
WV7302130000Medicaid