Healthcare Provider Details

I. General information

NPI: 1245655372
Provider Name (Legal Business Name): CARLA L GUDORF OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 MAIN ST #234
BUFFALO NY
14214-2152
US

IV. Provider business mailing address

2495 MAIN ST #234
BUFFALO NY
14214-2152
US

V. Phone/Fax

Practice location:
  • Phone: 716-836-5929
  • Fax: 716-836-6057
Mailing address:
  • Phone: 716-836-5929
  • Fax: 716-836-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number115917
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number115917
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number019199-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number019199-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: