Provider Demographics
NPI:1831324912
Name:MICK, CAROLYN P (COTA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:P
Last Name:MICK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:P
Other - Last Name:SASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:9190 PRIORITY WAY WEST DR STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1437
Mailing Address - Country:US
Mailing Address - Phone:317-805-4963
Mailing Address - Fax:317-818-0720
Practice Address - Street 1:9190 PRIORITY WAY WEST DR STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1437
Practice Address - Country:US
Practice Address - Phone:317-805-4963
Practice Address - Fax:317-818-0720
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001391A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant