Provider Demographics
NPI:1548268212
Name:ROCKHOLM, CAROLYN S (PT)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:S
Last Name:ROCKHOLM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:CAROLYN
Other - Middle Name:S
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2141 SE 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3913
Mailing Address - Country:US
Mailing Address - Phone:503-830-0026
Mailing Address - Fax:
Practice Address - Street 1:201 NE PARK PLAZA DR STE 246
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5874
Practice Address - Country:US
Practice Address - Phone:360-696-1070
Practice Address - Fax:360-737-0200
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112552Medicare UPIN