Provider Demographics
NPI:1063688828
Name:CARVER, LEWIS GLENN (COTA)
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:GLENN
Last Name:CARVER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 AZALEA ST SE
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8744
Mailing Address - Country:US
Mailing Address - Phone:219-987-2894
Mailing Address - Fax:
Practice Address - Street 1:614 AZALEA ST SE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8744
Practice Address - Country:US
Practice Address - Phone:219-987-2894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001364A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant