Basic Information
| Provider Information | |||||||||
| NPI: | 1396395547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | SWEDEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 FINDLAY ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546685 | ||||||||
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| Practice Location | |||||||||
| Address1: | 411 COURT ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2019 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.170774 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | QMHS | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | LCDCII.161629 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0370592 | 05 | OH | MEDICAID |