Provider Demographics
NPI:1184953465
Name:ABBOTT, CARMEN (PT)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 S CLINKENBEARD RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65010-9713
Mailing Address - Country:US
Mailing Address - Phone:573-657-4507
Mailing Address - Fax:
Practice Address - Street 1:1100 CLUB VILLAGE DR STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4411
Practice Address - Country:US
Practice Address - Phone:573-256-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist