Provider Demographics
NPI:1760630313
Name:SHORTRIDGE, CARRIE (PTA, ATC)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:
Last Name:SHORTRIDGE
Suffix:
Gender:F
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-0358
Mailing Address - Country:US
Mailing Address - Phone:765-675-8119
Mailing Address - Fax:765-675-8257
Practice Address - Street 1:514 STATE ROAD 32 E
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8767
Practice Address - Country:US
Practice Address - Phone:877-366-2663
Practice Address - Fax:317-867-7701
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001754A225200000X
IN36000474A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer