Healthcare Provider Details

I. General information

NPI: 1194053843
Provider Name (Legal Business Name): CAROLINA RODARTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 KETTNER BLVD SUITE 1A4
SAN DIEGO CA
92101-1250
US

IV. Provider business mailing address

2535 KETTNER BLVD SUITE 1A4
SAN DIEGO CA
92101-1250
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0701
  • Fax: 619-615-0705
Mailing address:
  • Phone: 619-615-0701
  • Fax: 619-615-0705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF65128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: