Provider Demographics
NPI:1225792476
Name:TETER, CARISSA J (COTA/L)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:J
Last Name:TETER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 EAST 56TH ST.
Mailing Address - Street 2:STE. A
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8628
Mailing Address - Country:US
Mailing Address - Phone:308-233-5060
Mailing Address - Fax:308-233-5062
Practice Address - Street 1:920 EAST 56TH ST.
Practice Address - Street 2:STE. A
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8628
Practice Address - Country:US
Practice Address - Phone:308-233-5060
Practice Address - Fax:308-233-5062
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1640224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant