Provider Demographics
NPI:1053872689
Name:TICKER, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:TICKER
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 1:1167 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 BARCLAY ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1593
Practice Address - Country:US
Practice Address - Phone:215-860-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT027621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist