Basic Information
| Provider Information | |||||||||
| NPI: | 1013454057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7344 MABELS WAY | ||||||||
| Address2: | |||||||||
| City: | LOVES PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611115375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192399304 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5666 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611082425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152262000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2017 | ||||||||
| LastUpdateDate: | 02/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070019496 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.