Provider Demographics
NPI:1558862565
Name:ROGERS, CARLY HOPE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:HOPE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 SUGARLAND DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-8176
Mailing Address - Country:US
Mailing Address - Phone:903-530-5151
Mailing Address - Fax:
Practice Address - Street 1:4062 SUMMERHILL SQ
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2730
Practice Address - Country:US
Practice Address - Phone:903-530-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215031224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant