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NPI Code Detail

MEDICARE: MS. CORONDA TYEAST CARTER

MEDICARE: MS. CORONDA TYEAST CARTER
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
1101Y00000XCounselor
2390200000XStudent in an Organized Health Care Education/Training ProgramIMF55564CA
3101YM0800XMental Health Counselor
4106H00000XMarriage & Family TherapistIMF55564CA
5101YM0800XMental Health CounselorIMF79317CA

General Provider Information

NPI Number : 1700915451
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. CORONDA TYEAST CARTER
Provider Business Mailing Address
First Line : 470 CHADBOURNE RD STE F
Second Line :
City : FAIRFIELD
State : CA
Zip : 94534-9620
Country : US
Telephone Number : 707-557-4560
Fax Number : 707-557-7909
Provider Business Practice Location Address
First Line : 470 CHADBOURNE RD STE F
Second Line :
City : FAIRFIELD
State : CA
Zip : 94534-9620
Country : US
Telephone Number : 707-557-4560
Fax Number : 707-557-7909
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2007
Last Update Date : 04/03/2017

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