Provider Demographics
NPI:1104277151
Name:VALENTINE, CARLY L
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:L
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E MAIN STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-522-3722
Mailing Address - Fax:406-522-0018
Practice Address - Street 1:612 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3719
Practice Address - Country:US
Practice Address - Phone:406-522-3722
Practice Address - Fax:406-522-0018
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OT-TMP-4406225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics