Provider Demographics
NPI:1578014338
Name:CORBALLY-CARSON, JULIA (LMT)
Entity Type:Individual
Prefix:MS
First Name:JULIA
Middle Name:
Last Name:CORBALLY-CARSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 554
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12151
Mailing Address - Country:US
Mailing Address - Phone:518-937-3264
Mailing Address - Fax:
Practice Address - Street 1:22 ANDREW AVE
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12151-7713
Practice Address - Country:US
Practice Address - Phone:518-937-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27028659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist