Provider Demographics
NPI:1235639592
Name:MYERS, CAROLYN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:MYERS
Suffix:
Gender:F
Credentials: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:RR 2 BOX 2761
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:MO
Mailing Address - Zip Code:65746-9314
Mailing Address - Country:US
Mailing Address - Phone:812-686-8683
Mailing Address - Fax:
Practice Address - Street 1:223 SOUTH JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608
Practice Address - Country:US
Practice Address - Phone:417-581-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009070225X00000X
MO2011016662225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist