Provider Demographics
NPI:1730505934
Name:TOLBERT, CARLY
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:GOMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:1262 SOLLENBERGER RD
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17202-8635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18889 CROGHAN PIKE
Practice Address - Street 2:
Practice Address - City:ORBISONIA
Practice Address - State:PA
Practice Address - Zip Code:17243-9685
Practice Address - Country:US
Practice Address - Phone:814-447-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007701224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant