Provider Demographics
NPI:1427201276
Name:RILEY, CARLA (PTA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 US HIGHWAY 98 W
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-7230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7720 US HIGHWAY 98 W
Practice Address - Street 2:SUITE 220
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-7230
Practice Address - Country:US
Practice Address - Phone:850-123-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 19826225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant