Provider Demographics
NPI:1861443236
Name:LETNER, CAROL SUE (DPT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:SUE
Last Name:LETNER
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 1:4290 E TOMAHAWK DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-7502
Mailing Address - Country:US
Mailing Address - Phone:847-571-4313
Mailing Address - Fax:
Practice Address - Street 1:4165 N BANK ST STE A
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2725
Practice Address - Country:US
Practice Address - Phone:928-351-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT30030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ67429Medicare UPIN
ILK26845Medicare ID - Type Unspecified