Healthcare Provider Details

I. General information

NPI: 1578747267
Provider Name (Legal Business Name): AMY SUE CARTER CADC-II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GRAPEVINE RD. #G27
VISTA CA
92083
US

IV. Provider business mailing address

200 GRAPEVINE RD APT.#G27
VISTA CA
92083-4037
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-3672
  • Fax:
Mailing address:
  • Phone: 760-744-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01025679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: