Provider Demographics
NPI:1134297922
Name:CARLSON, POLLY S (OTR/L)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:S
Last Name:CARLSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:288 DEXTER RD APT 104
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-4136
Mailing Address - Country:US
Mailing Address - Phone:304-479-3210
Mailing Address - Fax:
Practice Address - Street 1:288 DEXTER RD APT 104
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-4136
Practice Address - Country:US
Practice Address - Phone:304-479-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010299225X00000X
NC13086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017671860001Medicaid