Healthcare Provider Details

I. General information

NPI: 1750809711
Provider Name (Legal Business Name): CARRIN E. LICHTY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MINERAL POINT AVE
JANESVILLE WI
53548-2940
US

IV. Provider business mailing address

1000 MINERAL POINT AVE
JANESVILLE WI
53548-2940
US

V. Phone/Fax

Practice location:
  • Phone: 608-756-6000
  • Fax: 608-755-7892
Mailing address:
  • Phone: 608-756-6000
  • Fax: 608-755-7892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6104-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: