Healthcare Provider Details

I. General information

NPI: 1205238318
Provider Name (Legal Business Name): CARLY POLLACK CCN, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 ROSEWOOD AVE
AUSTIN TX
78702-2023
US

IV. Provider business mailing address

3111 CORBIN LN
AUSTIN TX
78704-5497
US

V. Phone/Fax

Practice location:
  • Phone: 512-243-7473
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number5046
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: