Provider Demographics
NPI:1821662339
Name:BAX, CARLY GOODMAN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:GOODMAN
Last Name:BAX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:MORGAN
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1337 MARLBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3214
Mailing Address - Country:US
Mailing Address - Phone:862-432-2659
Mailing Address - Fax:
Practice Address - Street 1:1010 N HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-2334
Practice Address - Country:US
Practice Address - Phone:267-978-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician