Provider Demographics
NPI:1457935686
Name:CARROLL, PHILLIP SEAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:SEAN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 N CLAUD AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1424
Mailing Address - Country:US
Mailing Address - Phone:925-278-3176
Mailing Address - Fax:
Practice Address - Street 1:1821 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2221
Practice Address - Country:US
Practice Address - Phone:931-222-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019022794225100000X
TX1318710225100000X
TN13333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist