Healthcare Provider Details

I. General information

NPI: 1962866905
Provider Name (Legal Business Name): CARSON CARPENTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 BAIRD AVE
RESEDA CA
91335-4150
US

IV. Provider business mailing address

7101 BAIRD AVE
RESEDA CA
91335-4150
US

V. Phone/Fax

Practice location:
  • Phone: 818-342-5897
  • Fax: 818-975-5008
Mailing address:
  • Phone: 818-342-5897
  • Fax: 818-975-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number91633
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: