Provider Demographics
NPI:1629275847
Name:CARPENTER, PHILLIP D (OT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 CROSS LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-1935
Mailing Address - Country:US
Mailing Address - Phone:318-635-2044
Mailing Address - Fax:
Practice Address - Street 1:1418 CROSS LAKE CIRLE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-1935
Practice Address - Country:US
Practice Address - Phone:318-635-2044
Practice Address - Fax:
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
LAZ11082225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist