Provider Demographics
NPI:1861267999
Name:MATLOCK, CARLY P (IAYT, YOGA THERAPIST)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:P
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:IAYT, YOGA THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 LAGUNA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2415 LAGUNA CANYON RD
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-1139
Practice Address - Country:US
Practice Address - Phone:714-391-0038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health