Provider Demographics
NPI:1487024352
Name:CARROLL, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 HAGEN LN
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1617
Mailing Address - Country:US
Mailing Address - Phone:708-957-2531
Mailing Address - Fax:
Practice Address - Street 1:2113 HAGEN LN
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1617
Practice Address - Country:US
Practice Address - Phone:708-957-2531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-04
Last Update Date:2015-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070004045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist