Healthcare Provider Details

I. General information

NPI: 1912605130
Provider Name (Legal Business Name): CARLY ANN OLVER DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 TAUGHANNOCK BLVD
ITHACA NY
14850-3251
US

IV. Provider business mailing address

1468 CODDINGTON RD
BROOKTONDALE NY
14817-9757
US

V. Phone/Fax

Practice location:
  • Phone: 607-252-3500
  • Fax:
Mailing address:
  • Phone: 607-337-8546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number049910
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: