Healthcare Provider Details

I. General information

NPI: 1841492923
Provider Name (Legal Business Name): CAROL TREACY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 7TH ST W
DICKINSON ND
58601-4335
US

IV. Provider business mailing address

3170 121ST AVE SW
DICKINSON ND
58601-9729
US

V. Phone/Fax

Practice location:
  • Phone: 701-456-4000
  • Fax: 701-456-4805
Mailing address:
  • Phone: 701-290-3849
  • Fax: 701-456-4805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number997
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: