Healthcare Provider Details

I. General information

NPI: 1720724446
Provider Name (Legal Business Name): CARNELIAN PSYCHOLOGICAL AND EDUCATIONAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12522 MOORPARK ST # 108
STUDIO CITY CA
91604-1355
US

IV. Provider business mailing address

12522 MOORPARK ST # 107
STUDIO CITY CA
91604-1355
US

V. Phone/Fax

Practice location:
  • Phone: 818-666-9434
  • Fax:
Mailing address:
  • Phone: 818-666-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name: LYRE FRIBOURG
Title or Position: OWNER
Credential: PHD
Phone: 818-666-9434