Provider Demographics
NPI:1700867645
Name:PAPE, CAROLYN DALE (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:DALE
Last Name:PAPE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-8010
Mailing Address - Country:US
Mailing Address - Phone:618-549-1544
Mailing Address - Fax:
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-942-2171
Practice Address - Fax:618-351-4926
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist