Provider Demographics
NPI:1265503759
Name:CARRASCO, CONNIE B (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:CONNIE
Middle Name:B
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:CONSUELO
Other - Middle Name:B
Other - Last Name:CARRASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTRL
Mailing Address - Street 1:412 MERRICK ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3219
Mailing Address - Country:US
Mailing Address - Phone:419-385-5978
Mailing Address - Fax:419-385-5978
Practice Address - Street 1:1621 S BYRNE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-3456
Practice Address - Country:US
Practice Address - Phone:419-385-5978
Practice Address - Fax:419-385-5978
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05408225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist