Healthcare Provider Details

I. General information

NPI: 1225645047
Provider Name (Legal Business Name): CARLY GRACE SPONSELLER RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403B GARDEN VILLA LN
AUSTIN TX
78704-6915
US

IV. Provider business mailing address

8769 SUGAR GUM RD
RIVERSIDE CA
92508-3065
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 949-750-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberRBT-20-134539
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: