Healthcare Provider Details

I. General information

NPI: 1659427920
Provider Name (Legal Business Name): CAROLYN ANN FARRELL MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROLYN ANN FARRELL-SHAW M FT

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6216 B HIGHWAY SUITE G
FELTON CA
95018-4058
US

IV. Provider business mailing address

6216 B HIGHWAY 9 SUITE G
FELTON CA
95018
US

V. Phone/Fax

Practice location:
  • Phone: 530-321-8545
  • Fax: 530-566-1380
Mailing address:
  • Phone: 831-325-6647
  • Fax: 530-566-1380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC43898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: