Healthcare Provider Details

I. General information

NPI: 1578175592
Provider Name (Legal Business Name): CARLY YSIDRON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY SPRINGS RD
HOLLY SPRINGS NC
27540-9027
US

IV. Provider business mailing address

217 COLVARD FARMS RD
DURHAM NC
27713-7043
US

V. Phone/Fax

Practice location:
  • Phone: 919-557-2660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCOND.20201520-SP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: