Provider Demographics
NPI:1669518833
Name:GRIFFIN, CARRIE LEA (OT)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEA
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:LEA
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:8031 W CENTER RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3158
Mailing Address - Country:US
Mailing Address - Phone:402-391-5002
Mailing Address - Fax:402-343-1278
Practice Address - Street 1:8031 W CENTER RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3158
Practice Address - Country:US
Practice Address - Phone:402-391-5002
Practice Address - Fax:402-343-1278
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111657225X00000X
IA001893225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA001893OtherSTATE LICENSURE
TX111657OtherLICENSE