Provider Demographics
NPI:1194867754
Name:DOUGLAS, CARLA LOUISE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:LOUISE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FAWN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1071
Mailing Address - Country:US
Mailing Address - Phone:314-452-4947
Mailing Address - Fax:636-379-9655
Practice Address - Street 1:20 FAWN OAKS DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-1071
Practice Address - Country:US
Practice Address - Phone:314-452-4947
Practice Address - Fax:636-379-9655
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001033078225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist