Healthcare Provider Details

I. General information

NPI: 1497941835
Provider Name (Legal Business Name): CAROL MEHLBERG CARBERRY BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. CAROL NOEL CARBERRY

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 GILDA DR
ST AUGUSTINE FL
32086-7605
US

IV. Provider business mailing address

745 GILDA DR
ST AUGUSTINE FL
32086-7605
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-7968
  • Fax: 904-794-7968
Mailing address:
  • Phone: 904-794-7968
  • Fax: 904-794-7968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: