Provider Demographics
NPI:1174186977
Name:REILLY, CARLY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 CALABASAS RD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-0418
Mailing Address - Country:US
Mailing Address - Phone:831-818-4183
Mailing Address - Fax:
Practice Address - Street 1:2 SCHOOL WAY
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-9716
Practice Address - Country:US
Practice Address - Phone:831-818-4183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
UT10444837-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer