Provider Demographics
NPI:1841959574
Name:GOMOLCHAK, CARRIE B (PTA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:B
Last Name:GOMOLCHAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 CARSON CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28681
Mailing Address - Country:US
Mailing Address - Phone:619-252-6516
Mailing Address - Fax:
Practice Address - Street 1:12825 MINNIEVILLE RD STE 201
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3602
Practice Address - Country:US
Practice Address - Phone:703-647-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACP007854A225200000X
NCCP017914A225200000X
NCA3852225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant