Provider Demographics
NPI:1740024868
Name:RUSEK-PETERSON, CARLY TENGES (OTD, OTR/L, ATP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:TENGES
Last Name:RUSEK-PETERSON
Suffix:
Gender:F
Credentials:OTD, OTR/L, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5182 W WOOD OWL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-5107
Mailing Address - Country:US
Mailing Address - Phone:515-867-0790
Mailing Address - Fax:
Practice Address - Street 1:5182 W WOOD OWL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-5107
Practice Address - Country:US
Practice Address - Phone:515-867-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008394225XP0019X
AZ96511225CA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner