Provider Demographics
NPI:1750323689
Name:FRIES, CAROLYN A (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:FRIES
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 1:512 SE WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-8231
Mailing Address - Country:US
Mailing Address - Phone:918-333-4343
Mailing Address - Fax:918-333-4355
Practice Address - Street 1:2234 W HOUSTON ST STE B
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3519
Practice Address - Country:US
Practice Address - Phone:918-333-4343
Practice Address - Fax:918-333-4355
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200001580BMedicaid
OK312529YUQZMedicare PIN
OK$$$$$$$$$PMedicare PIN