Provider Demographics
NPI:1740366657
Name:CARROLL, RYAN JOSEPH (MAED, LAT, ATC, OTC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JOSEPH
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MAED, LAT, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8668
Mailing Address - Country:US
Mailing Address - Phone:574-930-6067
Mailing Address - Fax:
Practice Address - Street 1:1201 MICHIGAN AVE STE 140
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1530
Practice Address - Country:US
Practice Address - Phone:574-722-3338
Practice Address - Fax:574-753-1551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001087A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer