Healthcare Provider Details

I. General information

NPI: 1427351725
Provider Name (Legal Business Name): MISS CARLY RAE GELVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 DANBURY RD
WILTON CT
06897-4429
US

IV. Provider business mailing address

12901 NE 28TH ST APT 226
VANCOUVER WA
98682-1284
US

V. Phone/Fax

Practice location:
  • Phone: 203-834-3083
  • Fax: 800-970-5001
Mailing address:
  • Phone: 360-880-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP1 60190917
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8683
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: