1093054082 NPI number — CARLY LYNNE MOUNT PSY.D.

Table of content: (NPI 1811941172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093054082 NPI number — CARLY LYNNE MOUNT PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOUNT
Provider First Name:
CARLY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MELCHER
Provider Other First Name:
CARLY
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093054082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 HICKMAN RD.
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
CHARLOTTESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-320-2907
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 HICKMAN RD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22911-3572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-320-2907
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  0810005487 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47-1710406 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".