Provider Demographics
NPI:1700446721
Name:MACHACEK, CARLY MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MICHELLE
Last Name:MACHACEK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:MICHELLE
Other - Last Name:SLAGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:
Practice Address - Street 1:9901 N KNOXVILLE AVE STE D
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1433
Practice Address - Country:US
Practice Address - Phone:309-243-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
KS11-063932251X0800X
MO20190312592251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist