Provider Demographics
NPI:1235636226
Name:CARPENTER, ERNEST III (LOTR)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:CARPENTER
Suffix:III
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7607 FERN AVE STE 704
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5744
Mailing Address - Country:US
Mailing Address - Phone:318-828-1450
Mailing Address - Fax:
Practice Address - Street 1:7607 FERN AVE STE 704
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5744
Practice Address - Country:US
Practice Address - Phone:318-828-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12249225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist