Basic Information
| Provider Information | |||||||||
| NPI: | 1194984484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASCARELLA | ||||||||
| FirstName: | CARLTON | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14360 SAINT ANDREWS DR | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923954358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602435417 | ||||||||
| FaxNumber: | 7605134696 | ||||||||
| Practice Location | |||||||||
| Address1: | 14360 SAINT ANDREWS DR | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923954358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602435417 | ||||||||
| FaxNumber: | 7605134696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 10/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 29791 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.