Provider Demographics
NPI:1922199553
Name:EMMONS, CARRIE M (MPT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:M
Last Name:EMMONS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:M
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:25012 104TH AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-2821
Practice Address - Country:US
Practice Address - Phone:253-856-3477
Practice Address - Fax:253-856-3478
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8922203OtherCRIME VICTIMS
WA8334898Medicaid
WAEM5142OtherREGENCE BLUE SHIELD
WA118314OtherDEPT OF LABOR & INDUSTRY
WA650015209OtherRAILROAD MEDICARE
WAA002OtherTRICARE
WA8922203OtherCRIME VICTIMS
WAGAB06850Medicare PIN
WA650015209OtherRAILROAD MEDICARE