Provider Demographics
NPI:1417090259
Name:PHARES, CAROL (OTR)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:PHARES
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 1:2204 RANCHO ORO AVE SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8729
Mailing Address - Country:US
Mailing Address - Phone:505-896-9722
Mailing Address - Fax:
Practice Address - Street 1:4216 BALLOON PARK RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5801
Practice Address - Country:US
Practice Address - Phone:505-344-5470
Practice Address - Fax:505-344-9343
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM811225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ2696Medicaid
NM811OtherNM OT STATE LICENSE