Healthcare Provider Details

I. General information

NPI: 1134702566
Provider Name (Legal Business Name): CARLY ZOMICK MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

666 UPAS ST UNIT 1605
SAN DIEGO CA
92103-5036
US

IV. Provider business mailing address

666 UPAS ST UNIT 1605
SAN DIEGO CA
92103-5036
US

V. Phone/Fax

Practice location:
  • Phone: 847-331-2155
  • Fax:
Mailing address:
  • Phone: 847-331-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: