Provider Demographics
NPI:1235784638
Name:PETERS, CARLY NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:NICOLE
Last Name:PETERS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15825 SPYGLASS TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5673
Mailing Address - Country:US
Mailing Address - Phone:210-602-7197
Mailing Address - Fax:
Practice Address - Street 1:516 176TH ST E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8335
Practice Address - Country:US
Practice Address - Phone:253-683-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-03
Last Update Date:2019-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60943567225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist