Provider Demographics
NPI:1578705810
Name:BECKER, CAROL R (MS, ATC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:R
Last Name:BECKER
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3532 ROUTE 77
Mailing Address - Street 2:
Mailing Address - City:VARYSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14167-9758
Mailing Address - Country:US
Mailing Address - Phone:815-761-0914
Mailing Address - Fax:
Practice Address - Street 1:5795 LEWISTON RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-2152
Practice Address - Country:US
Practice Address - Phone:716-286-8612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer