Healthcare Provider Details

I. General information

NPI: 1851649271
Provider Name (Legal Business Name): CARLOS MANUEL LAACK LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5747 LAUREL CANYON BLVD APT 32
VALLEY VILLAGE CA
91607-1253
US

IV. Provider business mailing address

41 S WAKE FOREST AVE UNIT 3786
VENTURA CA
93006-8039
US

V. Phone/Fax

Practice location:
  • Phone: 805-214-8233
  • Fax:
Mailing address:
  • Phone: 805-214-8233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number114823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: