Provider Demographics
NPI:1437641834
Name:CARPENTER, KELLY MARIE (CMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8036
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95155-8036
Mailing Address - Country:US
Mailing Address - Phone:669-235-7754
Mailing Address - Fax:
Practice Address - Street 1:2075 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3513
Practice Address - Country:US
Practice Address - Phone:669-235-7754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist