Provider Demographics
NPI:1205238318
Name:POLLACK, CARLY (CCN, MS)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:POLLACK
Suffix:
Gender:F
Credentials:CCN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 CORBIN LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-2023
Practice Address - Country:US
Practice Address - Phone:512-243-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5046133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education