Healthcare Provider Details

I. General information

NPI: 1831213958
Provider Name (Legal Business Name): CARTER CAMPBELL GARDNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SPRING STREET SUITE 204
LA MESA CA
91941-0237
US

IV. Provider business mailing address

2646 SEATTLE DRIVE
EL CAJON CA
92020-1774
US

V. Phone/Fax

Practice location:
  • Phone: 619-627-7701
  • Fax: 619-644-5751
Mailing address:
  • Phone: 619-627-7701
  • Fax: 619-644-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSY.10888
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY10888
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: