Provider Demographics
NPI:1780145037
Name:STANTON, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:STANTON
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 1:104 S 20TH ST STE 12
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-4410
Mailing Address - Country:US
Mailing Address - Phone:215-469-1782
Mailing Address - Fax:
Practice Address - Street 1:1777 SENTRY PKWY W STE 300
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2211
Practice Address - Country:US
Practice Address - Phone:215-767-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC010650101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional