Healthcare Provider Details

I. General information

NPI: 1629511134
Provider Name (Legal Business Name): CARLY ASHLEY CARPENTER ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: N/A N/A N/A N/A

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063 WHITTIER BLVD STE 202
LOS ANGELES CA
90023-2536
US

IV. Provider business mailing address

1891 EFFIE ST
LOS ANGELES CA
90026-1793
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-2100
  • Fax:
Mailing address:
  • Phone: 323-644-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW85386
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW85386
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW85386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: