Provider Demographics
NPI:1356717060
Name:LENA, CARLY (PT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:LENA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:LENA
Other - Last Name:MOLLINEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7228 W PONTIAC DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9628
Mailing Address - Country:US
Mailing Address - Phone:623-866-3035
Mailing Address - Fax:
Practice Address - Street 1:1802 W PARKSIDE LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1322
Practice Address - Country:US
Practice Address - Phone:602-943-5472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist