Provider Demographics
NPI:1376888545
Name:CAROLLO, SUSANN (PTA)
Entity Type:Individual
Prefix:
First Name:SUSANN
Middle Name:
Last Name:CAROLLO
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 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:33900 HARPER AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-4258
Practice Address - Country:US
Practice Address - Phone:586-416-9100
Practice Address - Fax:586-416-9103
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001801225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant