Basic Information
| Provider Information | |||||||||
| NPI: | 1750323689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIES | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 SE WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740068231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183334343 | ||||||||
| FaxNumber: | 9183334355 | ||||||||
| Practice Location | |||||||||
| Address1: | 2234 W HOUSTON ST STE B | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740123519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183334343 | ||||||||
| FaxNumber: | 9183334355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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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 | 2731 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200001580B | 05 | OK | MEDICAID |