Healthcare Provider Details

I. General information

NPI: 1801701479
Provider Name (Legal Business Name): MAKENNA LYNN CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 E GUASTI RD STE 100
ONTARIO CA
91761-8661
US

IV. Provider business mailing address

24 GLOBE LN
LADERA RANCH CA
92694-1208
US

V. Phone/Fax

Practice location:
  • Phone: 840-201-5818
  • Fax:
Mailing address:
  • Phone: 949-359-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: