Provider Demographics
NPI:1437515285
Name:DAVIS, CAROL DIANE (OTR/L)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:DIANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-3252
Mailing Address - Country:US
Mailing Address - Phone:307-677-0669
Mailing Address - Fax:
Practice Address - Street 1:612 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3252
Practice Address - Country:US
Practice Address - Phone:307-677-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR-509225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist