Provider Demographics
NPI:1649775859
Name:PINE, CARRIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ELIZABETH
Last Name:PINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1493 WEST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05036-9584
Mailing Address - Country:US
Mailing Address - Phone:518-522-5340
Mailing Address - Fax:
Practice Address - Street 1:1493 WEST ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:VT
Practice Address - Zip Code:05036-9584
Practice Address - Country:US
Practice Address - Phone:518-522-5340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer