Healthcare Provider Details

I. General information

NPI: 1285996470
Provider Name (Legal Business Name): TINA L CARTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RUSSELL ST
KENNETT MO
63857-2102
US

IV. Provider business mailing address

311 MAIN ST
NEW MADRID MO
63869-1942
US

V. Phone/Fax

Practice location:
  • Phone: 573-717-1332
  • Fax:
Mailing address:
  • Phone: 573-748-2404
  • Fax: 573-748-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2006033312
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2006033312
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: