Provider Demographics
NPI:1891379756
Name:LYNCH, CARLY REBECCA (COTA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:REBECCA
Last Name:LYNCH
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 1:1049 N EDGE TRL
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1942
Mailing Address - Country:US
Mailing Address - Phone:608-845-2100
Mailing Address - Fax:608-845-2101
Practice Address - Street 1:1049 N EDGE TRL
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1942
Practice Address - Country:US
Practice Address - Phone:608-845-2100
Practice Address - Fax:608-845-2101
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI577427224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant