Provider Demographics
NPI:1861833568
Name:LEWIS, CARRIE J (MA OTR/L)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-3654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 S HOUSTON ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-9349
Practice Address - Country:US
Practice Address - Phone:217-824-3447
Practice Address - Fax:217-824-3447
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004838225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist