MEDICARE: PHILLIP V CARRACHER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW5643	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z9367	OTHER	FL	BC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336134717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP V CARRACHER LCSW

Provider Business Mailing Address
First Line	:	PO BOX 495755
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33949-5755
Country	:	US
Telephone Number	:	941-766-9555
Fax Number	:	941-766-1511

Provider Business Practice Location Address
First Line	:	3191 HARBOR BLVD
Second Line	:	SUITE A
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6755
Country	:	US
Telephone Number	:	941-766-9555
Fax Number	:	941-766-1511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/08/2007

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