Provider Demographics
NPI:1588156954
Name:SPROUL, CARLY (MP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SPROUL
Suffix:
Gender:F
Credentials:MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41108 HILLCREST LOOP
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8646
Mailing Address - Country:US
Mailing Address - Phone:503-338-8826
Mailing Address - Fax:
Practice Address - Street 1:811 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2462
Practice Address - Country:US
Practice Address - Phone:503-338-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist