Provider Demographics
NPI:1356018295
Name:POUTTU, CARLY LYNN (PT, DPT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:LYNN
Last Name:POUTTU
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 4TH ST APT 306
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-3363
Mailing Address - Country:US
Mailing Address - Phone:330-807-9045
Mailing Address - Fax:
Practice Address - Street 1:1605 HOPE ST STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2647
Practice Address - Country:US
Practice Address - Phone:626-737-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty