Provider Demographics
NPI:1841408838
Name:HENRY, CAROLYN GRAY (COTA)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:GRAY
Last Name:HENRY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23981 WANIGAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4205
Mailing Address - Country:US
Mailing Address - Phone:949-489-9567
Mailing Address - Fax:
Practice Address - Street 1:3 PURSUIT
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4213
Practice Address - Country:US
Practice Address - Phone:949-389-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1208224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant