=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790222107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | H MICHAEL CARPENTER PH.D. BCBA-D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2017
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 MANCHESTER WAY
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92782-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-856-2696
-----------------------------------------------------
Fax | 714-352-5458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 MANCHESTER WAY
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92782-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-856-2696
-----------------------------------------------------
Fax | 714-352-5458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-05-2160
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------