Provider Demographics
NPI:1508321167
Name:HALE, CARROLL R (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:CARROLL
Middle Name:R
Last Name:HALE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-3722
Mailing Address - Country:US
Mailing Address - Phone:409-382-7140
Mailing Address - Fax:
Practice Address - Street 1:315 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4903
Practice Address - Country:US
Practice Address - Phone:409-384-5768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2020111225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant