Provider Demographics
NPI:1285347955
Name:WISE, CAROL LEWIS (OTR/L)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LEWIS
Last Name:WISE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 COUNTRY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-1869
Mailing Address - Country:US
Mailing Address - Phone:781-424-0161
Mailing Address - Fax:
Practice Address - Street 1:1463 OAKFIELD DR STE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-3893
Practice Address - Country:US
Practice Address - Phone:813-655-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19406225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics