Healthcare Provider Details

I. General information

NPI: 1003207291
Provider Name (Legal Business Name): CHARLES DAVID CARR ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 VINE ST
LOS ANGELES CA
90038
US

IV. Provider business mailing address

100 W 1ST ST
LOS ANGELES CA
90012-4112
US

V. Phone/Fax

Practice location:
  • Phone: 323-769-6100
  • Fax:
Mailing address:
  • Phone: 213-996-1347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW79885
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: