Basic Information
| Provider Information | |||||||||
| NPI: | 1629725957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEYGANDT | ||||||||
| FirstName: | CARLY | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416501 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1942944050 | ||||||||
| FaxNumber: | 6317608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 11496 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463077106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192132222 | ||||||||
| FaxNumber: | 8477862156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2022 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056.014784 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 31007674A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.