Provider Demographics
NPI:1588679062
Name:MODEROW, ANGELA M (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:MODEROW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:CORIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1100 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5814
Mailing Address - Country:US
Mailing Address - Phone:704-355-4370
Mailing Address - Fax:704-355-4231
Practice Address - Street 1:101 E WT HARRIS BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-548-5780
Practice Address - Fax:704-548-5876
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211893Medicaid