Healthcare Provider Details

I. General information

NPI: 1134209620
Provider Name (Legal Business Name): MARY CARAWAN ELKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GREENVILLE BLVD SE
GREENVILLE NC
27858-4529
US

IV. Provider business mailing address

1101 GREENVILLE BLVD SE
GREENVILLE NC
27858-4529
US

V. Phone/Fax

Practice location:
  • Phone: 252-756-6533
  • Fax: 252-756-5746
Mailing address:
  • Phone: 252-756-6533
  • Fax: 252-756-5746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3142
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: