Provider Demographics
NPI:1427351725
Name:GELVIN, CARLY RAE
Entity type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:RAE
Last Name:GELVIN
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 1:12901 NE 28TH ST APT 226
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-1284
Mailing Address - Country:US
Mailing Address - Phone:360-880-5657
Mailing Address - Fax:
Practice Address - Street 1:64 DANBURY RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4429
Practice Address - Country:US
Practice Address - Phone:203-834-3083
Practice Address - Fax:800-970-5001
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60190917225200000X
OR8683225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant