Provider Demographics
NPI:1417230103
Name:TAYLOR, CARLY (OT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 IDALOU DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0531
Mailing Address - Country:US
Mailing Address - Phone:903-276-1885
Mailing Address - Fax:
Practice Address - Street 1:3410 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3729
Practice Address - Country:US
Practice Address - Phone:903-792-3003
Practice Address - Fax:903-794-1005
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211057224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211057OtherTEXAS BOARD OF THERAPY EXAMINERS