Provider Demographics
NPI:1548677958
Name:VAN KLEY, CARMEN LYNN (COTA)
Entity type:Individual
Prefix:MISS
First Name:CARMEN
Middle Name:LYNN
Last Name:VAN KLEY
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 1:140 S VIANT ST APT B
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-2362
Mailing Address - Country:US
Mailing Address - Phone:219-213-0604
Mailing Address - Fax:
Practice Address - Street 1:140 S VIANT ST APT B
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-2362
Practice Address - Country:US
Practice Address - Phone:219-213-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002666A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant