Provider Demographics
NPI:1598016560
Name:BARYLAK, CAROLYN JILL (OT)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:JILL
Last Name:BARYLAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:CAROLYN
Other - Middle Name:JILL
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:4925 CHELTENHAM PL
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5818
Mailing Address - Country:US
Mailing Address - Phone:404-217-0785
Mailing Address - Fax:
Practice Address - Street 1:11405 MEDLOCK BRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1688
Practice Address - Country:US
Practice Address - Phone:770-814-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003014225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist