Provider Demographics
NPI:1356966980
Name:GUILLORY, CAROL DEVERA (OTR)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:DEVERA
Last Name:GUILLORY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 HOLST ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77708-1531
Mailing Address - Country:US
Mailing Address - Phone:409-656-2367
Mailing Address - Fax:
Practice Address - Street 1:4535 HOLST ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-1531
Practice Address - Country:US
Practice Address - Phone:409-656-2367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-11-05
Deactivation Date:2020-09-28
Deactivation Code:
Reactivation Date:2020-11-05
Provider Licenses
StateLicense IDTaxonomies
TX108181225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist