Provider Demographics
NPI:1780131953
Name:CARROLL, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 CHESTNUT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8321
Mailing Address - Country:US
Mailing Address - Phone:847-657-3520
Mailing Address - Fax:847-657-3521
Practice Address - Street 1:2400 CHESTNUT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8321
Practice Address - Country:US
Practice Address - Phone:847-657-3520
Practice Address - Fax:847-657-3521
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700210432251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic