Provider Demographics
NPI:1659679751
Name:UNDERWOOD, AUSTIN CARLYSLE CLYSE (MOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:AUSTIN
Middle Name:CARLYSLE CLYSE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:AUSTIN
Other - Middle Name:CARLYSLE
Other - Last Name:CLYSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:7333 PIONEERS BLVD APT 225
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7502
Mailing Address - Country:US
Mailing Address - Phone:740-525-9902
Mailing Address - Fax:
Practice Address - Street 1:4405 NORMAL BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5551
Practice Address - Country:US
Practice Address - Phone:740-525-9902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1557225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist