Provider Demographics
NPI:1558777672
Name:PACKARD, CAROLINE (PT)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:PACKARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6645 RIGA ST NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9210
Mailing Address - Country:US
Mailing Address - Phone:440-463-5483
Mailing Address - Fax:
Practice Address - Street 1:933 3 MILE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1673
Practice Address - Country:US
Practice Address - Phone:616-785-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist