MEDICARE: MARA LENA CARLOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		AZ

General Provider Information

NPI Number	:	1346952132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARA LENA CARLOS

Provider Business Mailing Address
First Line	:	1612 E SOUTHERN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3534
Country	:	US
Telephone Number	:	520-907-1437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 E SOUTHERN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3534
Country	:	US
Telephone Number	:	520-907-1437
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2022
Last Update Date	:	12/23/2022

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Directions to “ MARA LENA CARLOS ” Practice Location

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