Provider Demographics
NPI:1801409115
Name:CARR, CONNIE C (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:C
Last Name:CARR
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 1:11392 S SKYLUX AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-5047
Mailing Address - Country:US
Mailing Address - Phone:801-870-0354
Mailing Address - Fax:
Practice Address - Street 1:365 W 1550 N
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6888
Practice Address - Country:US
Practice Address - Phone:801-618-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11873192-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1578082954OtherNPIII