Provider Demographics
NPI:1801426796
Name:WHITTINGTON, CARRLYSSA DAWN (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:CARRLYSSA
Middle Name:DAWN
Last Name:WHITTINGTON
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:CARRLYSSA
Other - Middle Name:DAWN
Other - Last Name:LEAVESLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1377 E CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-6844
Mailing Address - Country:US
Mailing Address - Phone:989-657-9490
Mailing Address - Fax:
Practice Address - Street 1:4929 S VAL VISTA DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-0664
Practice Address - Country:US
Practice Address - Phone:480-795-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007750225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist