Provider Demographics
NPI:1134902638
Name:CARROLL, JUSTIN EDWARD (AT,ATC, CSCS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:EDWARD
Last Name:CARROLL
Suffix:
Gender:M
Credentials:AT,ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 HEATH RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-9721
Mailing Address - Country:US
Mailing Address - Phone:616-443-6692
Mailing Address - Fax:
Practice Address - Street 1:8500 BURLINGAME AVE SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-6941
Practice Address - Country:US
Practice Address - Phone:161-687-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010011202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer