Provider Demographics
NPI:1013454057
Name:CARROLL, LAURA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7344 MABELS WAY
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-5375
Mailing Address - Country:US
Mailing Address - Phone:319-239-9304
Mailing Address - Fax:
Practice Address - Street 1:5666 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2425
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-29
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist