Basic Information
| Provider Information | |||||||||
| NPI: | 1053693267 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMONA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 JEFFERSON AVE. | ||||||||
| Address2: | SUITE #195 | ||||||||
| City: | WEST SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956052350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164032970 | ||||||||
| FaxNumber: | 9162045255 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 JEFFERSON AVE. | ||||||||
| Address2: | SUITE #195 | ||||||||
| City: | WEST SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956052350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164032970 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2011 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LCSW76096 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.