Provider Demographics
NPI:1477006278
Name:MAYFIELD, CARLY RENAE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:RENAE
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MISS
Other - First Name:CARLY
Other - Middle Name:RENAE
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:128 E MAIN ST STE 3B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-1367
Mailing Address - Country:US
Mailing Address - Phone:937-408-0238
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-1312
Practice Address - Country:US
Practice Address - Phone:937-521-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0049512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer