Provider Demographics
NPI:1225645047
Name:SPONSELLER, CARLY GRACE (RBT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:GRACE
Last Name:SPONSELLER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8769 SUGAR GUM RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-3065
Mailing Address - Country:US
Mailing Address - Phone:949-750-9690
Mailing Address - Fax:
Practice Address - Street 1:3403B GARDEN VILLA LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6915
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-134539247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other