Provider Demographics
NPI:1265803142
Name:PENHOLLOW, CARLY RENEE (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:RENEE
Last Name:PENHOLLOW
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-0431
Mailing Address - Country:US
Mailing Address - Phone:706-638-3880
Mailing Address - Fax:706-638-3890
Practice Address - Street 1:1711 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1623
Practice Address - Country:US
Practice Address - Phone:706-528-4207
Practice Address - Fax:706-528-4211
Is Sole Proprietor?:No
Enumeration Date:2015-10-17
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 308692251X0800X
GAPT013800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic