Provider Demographics
NPI:1790200491
Name:ROMNEY, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ROMNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 W BROADWAY ST STE G
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2902
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:
Practice Address - Street 1:420 W 4TH S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2319
Practice Address - Country:US
Practice Address - Phone:208-656-4017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health