Provider Demographics
NPI:1215112909
Name:BENALLY, CAROLYN D (PTA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:D
Last Name:BENALLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 SAN CARLOS RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1041
Mailing Address - Country:US
Mailing Address - Phone:505-553-1093
Mailing Address - Fax:
Practice Address - Street 1:1430 SAN CARLOS RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1041
Practice Address - Country:US
Practice Address - Phone:505-553-1093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0436225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA-0436OtherPT LICENSURE