Healthcare Provider Details

I. General information

NPI: 1336361971
Provider Name (Legal Business Name): LADY LAURA CARVAJAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E. SHIELDS AVE.
FRESNO CA
93726
US

IV. Provider business mailing address

4916 N. 9TH STREET APT 109
FRESNO CA
93726
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9040
  • Fax:
Mailing address:
  • Phone: 559-801-2732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: