Provider Demographics
NPI:1215642210
Name:PERCY, CARLY (MA, TLLP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:PERCY
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48571 S I 94 SERVCE DR APT 108
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1747
Mailing Address - Country:US
Mailing Address - Phone:480-215-6586
Mailing Address - Fax:
Practice Address - Street 1:3300 WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4200
Practice Address - Country:US
Practice Address - Phone:734-743-2828
Practice Address - Fax:734-527-6075
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000382103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical