Provider Demographics
NPI:1407991847
Name:CARLSON - NEIDEFFER, RANDI J (OTR/L)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:J
Last Name:CARLSON - NEIDEFFER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:JEAN
Other - Last Name:NEIDEFFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:104 SPRINGFIELD PL
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5407
Mailing Address - Country:US
Mailing Address - Phone:843-553-1665
Mailing Address - Fax:843-766-3478
Practice Address - Street 1:104 SPRINGFIELD PL
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5407
Practice Address - Country:US
Practice Address - Phone:843-553-1665
Practice Address - Fax:843-766-3478
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2990225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist