Provider Demographics
NPI:1982191839
Name:POLVERINI, CAROL JANE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JANE
Last Name:POLVERINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5166 FOREST VIEW CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-8602
Mailing Address - Country:US
Mailing Address - Phone:734-649-0445
Mailing Address - Fax:
Practice Address - Street 1:1200 EARHART RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2768
Practice Address - Country:US
Practice Address - Phone:734-929-6883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist