Provider Demographics
NPI:1720538218
Name:FIDALGO, CARYN (OT)
Entity type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:FIDALGO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8920 PENNEGROVE CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8138
Mailing Address - Country:US
Mailing Address - Phone:813-846-4019
Mailing Address - Fax:
Practice Address - Street 1:1002 UNITY CT
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7878
Practice Address - Country:US
Practice Address - Phone:704-283-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10415225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC72-0132BMedicaid