Provider Demographics
NPI:1912299264
Name:WATANABE, CARLY M
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:WATANABE
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 1:407 ULUNIU ST
Mailing Address - Street 2:#301
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2519
Mailing Address - Country:US
Mailing Address - Phone:808-261-4321
Mailing Address - Fax:808-261-4320
Practice Address - Street 1:407 ULUNIU ST
Practice Address - Street 2:#301
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2519
Practice Address - Country:US
Practice Address - Phone:808-261-4321
Practice Address - Fax:808-261-4320
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT3327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist