Provider Demographics
NPI:1609073873
Name:EARL, CAROL J (COTA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:EARL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4408 KINGSDALE DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-1421
Mailing Address - Country:US
Mailing Address - Phone:219-462-0755
Mailing Address - Fax:
Practice Address - Street 1:6040 LUTE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5008
Practice Address - Country:US
Practice Address - Phone:219-763-6858
Practice Address - Fax:219-763-4858
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000220A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant