Healthcare Provider Details

I. General information

NPI: 1568381960
Provider Name (Legal Business Name): CAROLYN RACHEL HAGERTY AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 W CULVER AVE APT 318
ORANGE CA
92868-4161
US

IV. Provider business mailing address

1920 W CULVER AVE APT 318
ORANGE CA
92868-4161
US

V. Phone/Fax

Practice location:
  • Phone: 626-862-7140
  • Fax:
Mailing address:
  • Phone: 626-862-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number155349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: