MEDICARE: SHANNON K. CARTER PSYCHOLOGIST, INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1417572694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHANNON K. CARTER PSYCHOLOGIST, INC.

Provider Business Mailing Address
First Line	:	716 N PRISCILLA LN
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-3138
Country	:	US
Telephone Number	:	323-459-9642
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 N AVENUE 50
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-3292
Country	:	US
Telephone Number	:	323-459-9642
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. SHANNON CARTER
Credential	:	PSYD
Telephone Number	:	323-459-9642

Provider Enumeration Date	:	06/12/2020
Last Update Date	:	09/06/2023

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