Provider Demographics
NPI:1356566731
Name:CARROLL, WANDA (PTA, LMT, CNA)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PTA, LMT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2836
Mailing Address - Country:US
Mailing Address - Phone:443-986-2959
Mailing Address - Fax:
Practice Address - Street 1:839 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2836
Practice Address - Country:US
Practice Address - Phone:443-986-2959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM00487174400000X, 225700000X
MDA3443225200000X
MDA00010416374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide