Provider Demographics
NPI:1760939433
Name:FELDEWERTH, CAROL J (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:J
Last Name:FELDEWERTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 FOX HILL CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5736
Mailing Address - Country:US
Mailing Address - Phone:618-444-3528
Mailing Address - Fax:
Practice Address - Street 1:1373 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1767
Practice Address - Country:US
Practice Address - Phone:618-467-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001976225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant