Provider Demographics
NPI:1689904393
Name:MEACHAM, CARLY VICTORIA (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:VICTORIA
Last Name:MEACHAM
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 HARRISBURG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-8258
Mailing Address - Country:US
Mailing Address - Phone:607-382-1426
Mailing Address - Fax:
Practice Address - Street 1:3942 PINE HILL RD
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-9782
Practice Address - Country:US
Practice Address - Phone:607-382-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015799-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist