Provider Demographics
NPI:1497941835
Name:CARBERRY, CAROL MEHLBERG (BA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:MEHLBERG
Last Name:CARBERRY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MRS
Other - First Name:CAROL
Other - Middle Name:NOEL
Other - Last Name:CARBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:745 GILDA DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7605
Mailing Address - Country:US
Mailing Address - Phone:904-794-7968
Mailing Address - Fax:904-794-7968
Practice Address - Street 1:745 GILDA DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7605
Practice Address - Country:US
Practice Address - Phone:904-794-7968
Practice Address - Fax:904-794-7968
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812228800Medicaid