Provider Demographics
NPI:1386115863
Name:POLLOCK, CARLY CECILIA
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:CECILIA
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 W WATERS AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2783
Mailing Address - Country:US
Mailing Address - Phone:813-932-5119
Mailing Address - Fax:
Practice Address - Street 1:9355 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3133
Practice Address - Country:US
Practice Address - Phone:727-579-7974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19677225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist