Healthcare Provider Details

I. General information

NPI: 1194064295
Provider Name (Legal Business Name): IVAN GABRIEL CARRASCO LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BELLE TER
BAKERSFIELD CA
93307-3871
US

IV. Provider business mailing address

PO BOX 1000
BAKERSFIELD CA
93302-1000
US

V. Phone/Fax

Practice location:
  • Phone: 661-635-2950
  • Fax:
Mailing address:
  • Phone: 661-868-6817
  • Fax: 661-868-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF77870
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT102699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: