Healthcare Provider Details

I. General information

NPI: 1902506751
Provider Name (Legal Business Name): CARLY MAE CLEARWATER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 UNION VALLEY RD
WEST MILFORD NJ
07480-1357
US

IV. Provider business mailing address

424 CANISTEAR RD
STOCKHOLM NJ
07460-1832
US

V. Phone/Fax

Practice location:
  • Phone: 860-575-0428
  • Fax:
Mailing address:
  • Phone: 860-575-0428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-320763
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number46TR00887900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: