Provider Demographics
NPI:1922219179
Name:PHELPS, CARL WADE (PTA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:WADE
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03290-6024
Mailing Address - Country:US
Mailing Address - Phone:603-942-5025
Mailing Address - Fax:
Practice Address - Street 1:307 PLAZA DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2455
Practice Address - Country:US
Practice Address - Phone:603-750-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0503225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant