Provider Demographics
NPI:1124079363
Name:CLAY-PINEDA, CAROLYN FAITH (PT)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:FAITH
Last Name:CLAY-PINEDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:CAROLYN
Other - Middle Name:FAITH
Other - Last Name:CLAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:N1179 WPA RD
Mailing Address - Street 2:
Mailing Address - City:VULCAN
Mailing Address - State:MI
Mailing Address - Zip Code:49892-8603
Mailing Address - Country:US
Mailing Address - Phone:906-563-9443
Mailing Address - Fax:906-563-9443
Practice Address - Street 1:W3101 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:VULCAN
Practice Address - State:MI
Practice Address - Zip Code:49892-8290
Practice Address - Country:US
Practice Address - Phone:906-563-9443
Practice Address - Fax:906-563-9443
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004236208100000X
WI3472-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650B21070-0OtherBCBS GROUP PIN
WI000280036Medicare PIN
MI650B21070-0OtherBCBS GROUP PIN