Provider Demographics
NPI:1134702566
Name:ZOMICK, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ZOMICK
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 1:666 UPAS ST UNIT 1605
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5036
Mailing Address - Country:US
Mailing Address - Phone:847-331-2155
Mailing Address - Fax:
Practice Address - Street 1:6540 LUSK BLVD STE C241
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2782
Practice Address - Country:US
Practice Address - Phone:619-933-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist