Healthcare Provider Details

I. General information

NPI: 1548717044
Provider Name (Legal Business Name): CARLOS LUIS SALAZAR PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-6877
  • Fax:
Mailing address:
  • Phone: 937-257-6877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810005992
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810005992
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: