Provider Demographics
NPI:1720718976
Name:PETERS, CAROLYN PATRICIA (OTR/L)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:PATRICIA
Last Name:PETERS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:PATRICIA
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1200 CORPORATE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2944
Mailing Address - Country:US
Mailing Address - Phone:423-777-6236
Mailing Address - Fax:
Practice Address - Street 1:1423 MAGNOLIA ST APT D
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3569
Practice Address - Country:US
Practice Address - Phone:228-256-6015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012890225X00000X
MSOT-4111225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist