Provider Demographics
NPI:1912605130
Name:OLVER, CARLY ANN (DPT, PT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:OLVER
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 CODDINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKTONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:14817-9757
Mailing Address - Country:US
Mailing Address - Phone:607-337-8546
Mailing Address - Fax:
Practice Address - Street 1:310 TAUGHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3251
Practice Address - Country:US
Practice Address - Phone:607-252-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY049910Medicaid