Provider Demographics
NPI:1023724382
Name:TEACHOUT, CARLEY NICOLE
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:NICOLE
Last Name:TEACHOUT
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 1:5703 STATE ROUTE 89
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:NY
Mailing Address - Zip Code:14541-9546
Mailing Address - Country:US
Mailing Address - Phone:315-857-6433
Mailing Address - Fax:
Practice Address - Street 1:337 NEPONSET AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3103
Practice Address - Country:US
Practice Address - Phone:617-265-2359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist