Provider Demographics
NPI:1134880750
Name:GOOLBIS, CARLY A
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:A
Last Name:GOOLBIS
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 1:24 AIRPORT RD STE 19
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784-1663
Mailing Address - Country:US
Mailing Address - Phone:603-562-5715
Mailing Address - Fax:
Practice Address - Street 1:24 AIRPORT RD STE 19
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-1663
Practice Address - Country:US
Practice Address - Phone:603-562-5715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program