Provider Demographics
NPI:1710060777
Name:GULLEDGE, CARISA JANE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CARISA
Middle Name:JANE
Last Name:GULLEDGE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2877 MCKENZIE RD
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-3413
Mailing Address - Country:US
Mailing Address - Phone:731-847-6731
Mailing Address - Fax:
Practice Address - Street 1:524 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATURVILLE
Practice Address - State:TN
Practice Address - Zip Code:38329-8101
Practice Address - Country:US
Practice Address - Phone:731-852-3591
Practice Address - Fax:731-852-2283
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1257224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant