Healthcare Provider Details

I. General information

NPI: 1780136200
Provider Name (Legal Business Name): CARRIE CARLSON OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4608 BLARNEY DR
CEDAR RAPIDS IA
52411-8069
US

IV. Provider business mailing address

4608 BLARNEY DR
CEDAR RAPIDS IA
52411-8069
US

V. Phone/Fax

Practice location:
  • Phone: 319-290-1292
  • Fax:
Mailing address:
  • Phone: 319-290-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number00162
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: