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General NPI Number Information
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NPI Number | 1518106632
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Entity Type | Individual
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Provider Name | CARLY ANN CLARK L.M.T
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Gender | Female
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Dates
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Enumeration Date | 02/12/2009
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Last Update Date | 02/12/2009
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Provider Practice Location Address
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Address Line | 127 W 79TH ST SUITE 4
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City | NEW YORK
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State | NY
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Zip | 10024-6416
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Country | US
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Telephone | 607-316-7918
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Fax |
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Provider Business Mailing Address
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Address Line | 1164 PACIFIC ST APT B1
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City | BROOKLYN
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State | NY
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Zip | 11216-2944
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Country | US
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Telephone | 607-316-7918
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 022370
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License Number State | NY
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