Provider Demographics
NPI:1609080258
Name:CARROLL, BRET D (PT)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:D
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W BUTTERNUT ST
Mailing Address - Street 2:
Mailing Address - City:ABBOTSFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54405-9546
Mailing Address - Country:US
Mailing Address - Phone:715-223-2959
Mailing Address - Fax:715-229-9482
Practice Address - Street 1:W4266 STATE HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:WI
Practice Address - Zip Code:54460-8932
Practice Address - Country:US
Practice Address - Phone:715-229-2172
Practice Address - Fax:715-229-9482
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4312-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40199400Medicaid