Provider Demographics
NPI:1750342614
Name:PHELAN, CAROLYN H (OTRL CHT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:H
Last Name:PHELAN
Suffix:
Gender:F
Credentials:OTRL CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 WASHINGTON ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2209
Mailing Address - Country:US
Mailing Address - Phone:619-299-5000
Mailing Address - Fax:619-299-1549
Practice Address - Street 1:770 WASHINGTON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2209
Practice Address - Country:US
Practice Address - Phone:619-299-5000
Practice Address - Fax:619-299-1549
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT461 9511000046225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WOT481BMedicare ID - Type Unspecified
WOT481AMedicare ID - Type Unspecified