Basic Information
| Provider Information | |||||||||
| NPI: | 1629511134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | ASHLEY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | N/A | ||||||||
| OtherFirstName: | N/A | ||||||||
| OtherMiddleName: | N/A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N/A | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1891 EFFIE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900261793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236442000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4063 WHITTIER BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900232536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232682100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2016 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
| 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 | 104100000X | ASW85386 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | ASW85386 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251B00000X | N | Agencies | Case Management | 101YM0800X | ASW85386 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.