Provider Demographics
NPI:1952319345
Name:STOKLOSA, CAROLYN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:STOKLOSA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 RIDGE RUNNER ROAD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
Mailing Address - Country:US
Mailing Address - Phone:505-425-1117
Mailing Address - Fax:505-454-7810
Practice Address - Street 1:2513 RIDGE RUNNER RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4972
Practice Address - Country:US
Practice Address - Phone:505-425-1117
Practice Address - Fax:505-454-7810
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00NM00Q090OtherBLUE CROSS BLUE SHIELD
NM77131282Medicaid