Provider Demographics
NPI:1609128727
Name:CARROLL, BETHANY MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:MARIE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15576 COLUMBARY CT
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4608
Mailing Address - Country:US
Mailing Address - Phone:952-217-3325
Mailing Address - Fax:
Practice Address - Street 1:15576 COLUMBARY CT
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-4608
Practice Address - Country:US
Practice Address - Phone:952-217-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2014-04-29
Deactivation Date:2013-02-28
Deactivation Code:
Reactivation Date:2014-04-29
Provider Licenses
StateLicense IDTaxonomies
MN104313225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
302015OtherNBCOT
MN104313OtherLICENSE