Healthcare Provider Details

I. General information

NPI: 1699374793
Provider Name (Legal Business Name): CARLY TEATS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 GRUBB RD
PALMYRA PA
17078-3514
US

IV. Provider business mailing address

3220 LINDEN PKWY
HARRISBURG PA
17110-9305
US

V. Phone/Fax

Practice location:
  • Phone: 717-838-5406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE1005263
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: