Healthcare Provider Details

I. General information

NPI: 1336015437
Provider Name (Legal Business Name): MANUEL CARVAJAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 LITTLE RIVER LN
TALLAHASSEE FL
32311-9485
US

IV. Provider business mailing address

1540 INTERNATIONAL PKWY STE 2000
LAKE MARY FL
32746-5096
US

V. Phone/Fax

Practice location:
  • Phone: 850-270-0620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number144.001380
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: