Healthcare Provider Details

I. General information

NPI: 1609528058
Provider Name (Legal Business Name): ASHLY CARBONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 JEFFERSON DR
LAKE CHARLES LA
70605-5713
US

IV. Provider business mailing address

133 JEFFERSON DR
LAKE CHARLES LA
70605-5713
US

V. Phone/Fax

Practice location:
  • Phone: 337-431-7194
  • Fax:
Mailing address:
  • Phone: 337-431-7194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9595
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: