Provider Demographics
NPI:1952732513
Name:CARLYLE, SERENITY (LAC)
Entity Type:Individual
Prefix:
First Name:SERENITY
Middle Name:
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9755
Mailing Address - Country:US
Mailing Address - Phone:206-491-3988
Mailing Address - Fax:
Practice Address - Street 1:1025 BRIXTON DR
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502-8831
Practice Address - Country:US
Practice Address - Phone:206-491-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005092171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist