Provider Demographics
NPI:1952042772
Name:THORNBROUGH, CARLA VERA
Entity Type:Individual
Prefix:
First Name:CARLA VERA
Middle Name:
Last Name:THORNBROUGH
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 1:2458 MURRAY PASS
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4156
Mailing Address - Country:US
Mailing Address - Phone:813-480-6915
Mailing Address - Fax:
Practice Address - Street 1:2458 MURRAY PASS
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-4156
Practice Address - Country:US
Practice Address - Phone:813-480-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty