Provider Demographics
NPI:1306351424
Name:CARLISLE, LAURA CARA
Entity type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:CARA
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURACARA
Other - Middle Name:CARLISLE
Other - Last Name:MOFFO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2440 W MARION AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-5153
Mailing Address - Country:US
Mailing Address - Phone:860-748-3130
Mailing Address - Fax:
Practice Address - Street 1:2440 W MARION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950
Practice Address - Country:US
Practice Address - Phone:860-748-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician