Basic Information
Provider Information | |||||||||
NPI: | 1194150722 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARLTON | ||||||||
FirstName: | STEPHANI | ||||||||
MiddleName: | FAE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1104 W IRONWOOD DR | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838142605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086761003 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 107 S DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992021510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098384651 | ||||||||
FaxNumber: | 5093632762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2013 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MG 60393692 | WA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 101YM0800X | LH60641907 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | MC 60393728 | WA | N |   | Behavioral Health & Social Service Providers | Counselor |   | 101Y00000X | LPC-5353 | ID | N |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 1194150722 | 05 | WA |   | MEDICAID |