Provider Demographics
NPI:1265559074
Name:FREESTONE, CARROLL S (COTA)
Entity type:Individual
Prefix:
First Name:CARROLL
Middle Name:S
Last Name:FREESTONE
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 1:804 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1416
Mailing Address - Country:US
Mailing Address - Phone:610-678-5618
Mailing Address - Fax:
Practice Address - Street 1:401 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:SCHUYLKILL HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17972-2211
Practice Address - Country:US
Practice Address - Phone:570-385-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP001840L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant