Provider Demographics
NPI:1699290221
Name:DESJARDINS, CARLIE (DPT)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:
Last Name:DESJARDINS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10102 S MAIN ST STE S
Mailing Address - Street 2:
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-3183
Mailing Address - Country:US
Mailing Address - Phone:336-307-3015
Mailing Address - Fax:336-307-3004
Practice Address - Street 1:10102 S MAIN ST STE S
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-3183
Practice Address - Country:US
Practice Address - Phone:336-307-3015
Practice Address - Fax:336-307-3004
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP17324OtherNC STATE LICENSE