Provider Demographics
NPI:1447549076
Name:CARTER, QWENETRA GEORGETTE (OT)
Entity type:Individual
Prefix:
First Name:QWENETRA
Middle Name:GEORGETTE
Last Name:CARTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 DONNIE AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-8918
Mailing Address - Country:US
Mailing Address - Phone:254-634-8505
Mailing Address - Fax:254-781-4312
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6249
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-781-4312
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009933225X00000X
TX114027225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114027OtherSTATE LICENSE NUMBER