Provider Demographics
NPI:1215214341
Name:AVERA, CAROL ANN (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:AVERA
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 SPANTON CRES
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9673
Mailing Address - Country:US
Mailing Address - Phone:912-704-4277
Mailing Address - Fax:
Practice Address - Street 1:179 SPANTON CRES
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9673
Practice Address - Country:US
Practice Address - Phone:912-704-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005162225X00000X
SCOT.4075OT225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist