Healthcare Provider Details

I. General information

NPI: 1740024868
Provider Name (Legal Business Name): CARLY TENGES RUSEK-PETERSON OTD, OTR/L, ATP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5182 W WOOD OWL DR
TUCSON AZ
85742-5107
US

IV. Provider business mailing address

5182 W WOOD OWL DR
TUCSON AZ
85742-5107
US

V. Phone/Fax

Practice location:
  • Phone: 515-867-0790
  • Fax:
Mailing address:
  • Phone: 515-867-0790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225CA2400X
TaxonomyAssistive Technology Practitioner Rehabilitation Counselor
License Number96511
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOTH-008394
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: