Provider Demographics
NPI:1275807570
Name:RUNKLES, CARLY (PT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:RUNKLES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 MORTON PLANT ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3398
Mailing Address - Country:US
Mailing Address - Phone:727-461-8464
Mailing Address - Fax:
Practice Address - Street 1:430 MORTON PLANT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3398
Practice Address - Country:US
Practice Address - Phone:727-461-8464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist