Provider Demographics
NPI:1073943601
Name:KOO, CARRIE M (LAC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:M
Last Name:KOO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 FLOWER LN
Mailing Address - Street 2:
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-4434
Mailing Address - Country:US
Mailing Address - Phone:732-533-3687
Mailing Address - Fax:
Practice Address - Street 1:242 ROUTE 79 N
Practice Address - Street 2:SUITE 11
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-2078
Practice Address - Country:US
Practice Address - Phone:732-858-1322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00102500171100000X
NY005179171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist