Healthcare Provider Details

I. General information

NPI: 1043451198
Provider Name (Legal Business Name): CARMEN LILY CARROUCHE RN, CNS, PMH-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 RITTER ST
SAN RAFAEL CA
94901-3323
US

IV. Provider business mailing address

16 RITTER ST
SAN RAFAEL CA
94901-3323
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-8182
  • Fax: 415-457-3490
Mailing address:
  • Phone: 415-457-8182
  • Fax: 415-457-3490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number23466
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number510142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: