Provider Demographics
NPI:1922372911
Name:PERSRAM, CAROLYN N
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:N
Last Name:PERSRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 GAIL CT
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4610
Mailing Address - Country:US
Mailing Address - Phone:516-256-0727
Mailing Address - Fax:
Practice Address - Street 1:688 GAIL CT
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4610
Practice Address - Country:US
Practice Address - Phone:516-256-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007665-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
007665-1OtherOCCUPATIONAL THERAPIST