Provider Demographics
NPI:1659609923
Name:FORTENBERRY, CARROL SHANE (PT)
Entity Type:Individual
Prefix:MR
First Name:CARROL
Middle Name:SHANE
Last Name:FORTENBERRY
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 1:2844 TRACELAND DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4200
Mailing Address - Country:US
Mailing Address - Phone:188-863-9692
Mailing Address - Fax:
Practice Address - Street 1:2844 TRACELAND AVE.
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:188-863-9692
Practice Address - Fax:662-680-5097
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0345225100000X
TNPT0000008246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist