Provider Demographics
NPI:1619482593
Name:CARPENTER, LAURA (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1258
Mailing Address - Country:US
Mailing Address - Phone:815-802-7503
Mailing Address - Fax:815-802-7514
Practice Address - Street 1:517 E NORTH ST
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1258
Practice Address - Country:US
Practice Address - Phone:815-802-7503
Practice Address - Fax:815-802-7514
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227008895225700000X
IL160.007954225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist