Provider Demographics
NPI:1992531834
Name:GOTHARD, CARLEE RAE ELIZABETH
Entity type:Individual
Prefix:
First Name:CARLEE
Middle Name:RAE ELIZABETH
Last Name:GOTHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2033 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8304
Practice Address - Country:US
Practice Address - Phone:833-587-1784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2549224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant