Provider Demographics
NPI:1508030446
Name:STEIN, CAROLYN MARY (PTA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARY
Last Name:STEIN
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 1:8520 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4604
Mailing Address - Country:US
Mailing Address - Phone:414-607-4120
Mailing Address - Fax:
Practice Address - Street 1:8520 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-4604
Practice Address - Country:US
Practice Address - Phone:414-607-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI607-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40451900Medicaid
WI607-019OtherPHYSICAL THERAPY ASSISTANT LICENSE