Healthcare Provider Details

I. General information

NPI: 1962938506
Provider Name (Legal Business Name): CAROL PEASE MS, CPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 N STOCKTON HILL RD #103-449
KINGMAN AZ
86409-0595
US

IV. Provider business mailing address

3880 N STOCKTON HILL RD #103-449
KINGMAN AZ
86409-0595
US

V. Phone/Fax

Practice location:
  • Phone: 928-303-5155
  • Fax:
Mailing address:
  • Phone: 928-303-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: