Provider Demographics
NPI:1861154452
Name:MCLARTY, CARLY (ND)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MCLARTY
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78650 AVENUE 42 APT 803
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-1352
Mailing Address - Country:US
Mailing Address - Phone:513-306-5963
Mailing Address - Fax:
Practice Address - Street 1:78900 AVENUE 47 STE 102
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2070
Practice Address - Country:US
Practice Address - Phone:760-771-5970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND1282175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty