Healthcare Provider Details

I. General information

NPI: 1023769650
Provider Name (Legal Business Name): ELAINA CARR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 MCCASKILL ST
CRESTVIEW FL
32536-2757
US

IV. Provider business mailing address

930 N FERDON BLVD
CRESTVIEW FL
32536-1706
US

V. Phone/Fax

Practice location:
  • Phone: 850-634-6243
  • Fax: 850-801-1118
Mailing address:
  • Phone: 850-331-2987
  • Fax: 850-398-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT21974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: