Provider Demographics
NPI:1902221179
Name:CARR, TIMOTHY (OTA/L)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CARR
Suffix:
Gender:M
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W FIFTH ST
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-2405
Mailing Address - Country:US
Mailing Address - Phone:330-386-2054
Mailing Address - Fax:
Practice Address - Street 1:425 W FIFTH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2405
Practice Address - Country:US
Practice Address - Phone:330-386-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.02542224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOTA.02542Medicaid