Provider Demographics
NPI:1710013651
Name:FAHERTY, CARON (OT)
Entity Type:Individual
Prefix:
First Name:CARON
Middle Name:
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 JENSEN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4750
Mailing Address - Country:US
Mailing Address - Phone:772-708-3751
Mailing Address - Fax:772-225-0843
Practice Address - Street 1:690 JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4750
Practice Address - Country:US
Practice Address - Phone:772-708-3751
Practice Address - Fax:772-225-0843
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1145225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0374YMedicare ID - Type UnspecifiedINDIVIDUAL #