Provider Demographics
NPI:1023187275
Name:VICAIN, CARLETTA RENEE (MFT)
Entity Type:Individual
Prefix:
First Name:CARLETTA
Middle Name:RENEE
Last Name:VICAIN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5424
Mailing Address - Country:US
Mailing Address - Phone:760-726-4900
Mailing Address - Fax:
Practice Address - Street 1:1011 CAMINO DEL MAR STE 240
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2655
Practice Address - Country:US
Practice Address - Phone:619-917-2032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF40145106H00000X
CA45789106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist