Provider Demographics
NPI:1871641951
Name:CARLYLE, TERRY JOE (ATC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:JOE
Last Name:CARLYLE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 CLOVER LANE SE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060
Mailing Address - Country:US
Mailing Address - Phone:507-451-1924
Mailing Address - Fax:
Practice Address - Street 1:903 S OAK AVE
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3200
Practice Address - Country:US
Practice Address - Phone:507-455-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1059225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist