Provider Demographics
NPI:1720356470
Name:PETTUS, CAROL YVONNE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:YVONNE
Last Name:PETTUS
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 1:14631 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2244
Mailing Address - Country:US
Mailing Address - Phone:913-488-9848
Mailing Address - Fax:913-897-0248
Practice Address - Street 1:14631 FLOYD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-2244
Practice Address - Country:US
Practice Address - Phone:913-488-9848
Practice Address - Fax:913-897-0248
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00006224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant