Provider Demographics
NPI:1033310230
Name:CARLSON, ROGER EARL (OTR)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:EARL
Last Name:CARLSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5724 ENSIGN RD
Mailing Address - Street 2:
Mailing Address - City:WEST FARMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44491-9721
Mailing Address - Country:US
Mailing Address - Phone:440-548-2745
Mailing Address - Fax:
Practice Address - Street 1:7233 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7137
Practice Address - Country:US
Practice Address - Phone:330-498-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH005255225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist