Provider Demographics
NPI:1295818466
Name:OSTERHOUT, CARMEN E (PT)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:E
Last Name:OSTERHOUT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4343 HOLLYGATE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1337
Mailing Address - Country:US
Mailing Address - Phone:630-659-6783
Mailing Address - Fax:
Practice Address - Street 1:4343 HOLLYGATE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1337
Practice Address - Country:US
Practice Address - Phone:630-659-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist