Provider Demographics
NPI:1265687578
Name:CARROLL, COLEEN O'CONNOR (PT)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:O'CONNOR
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 1:9353 SOUTHTOWNE FARMS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7042
Mailing Address - Country:US
Mailing Address - Phone:314-894-1727
Mailing Address - Fax:
Practice Address - Street 1:9353 SOUTHTOWNE FARMS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7042
Practice Address - Country:US
Practice Address - Phone:314-894-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO01941174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty