Basic Information
| Provider Information | |||||||||
| NPI: | 1750899720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRALES | ||||||||
| FirstName: | CARLO | ||||||||
| MiddleName: | MIGUEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3953 W 178TH ST APT B | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905043826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109776766 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1230 ROSECRANS AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902662496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104061500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2018 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-17-30298 | CA | Y |
No ID Information.