Provider Demographics
NPI:1154885051
Name:ROOP, CARLY M (RD, LDN)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:ROOP
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 OLD LANCASTER RD # 2B
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 SPRUCE ST # 304
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4022
Practice Address - Country:US
Practice Address - Phone:215-240-7883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004069133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered