Provider Demographics
NPI:1679704951
Name:CARROLL, THERESA A (DPT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:2106 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2402
Practice Address - Country:US
Practice Address - Phone:757-838-6678
Practice Address - Fax:757-838-8116
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679704951Medicaid
VAP00748138OtherRAILROAD MEDICARE
VA9409378OtherAETNA
VAC05954Medicare PIN
VA1679704951Medicaid