Provider Demographics
NPI:1043373913
Name:CARRAWAY, KIRSTEN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:L
Last Name:CARRAWAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WASHINGTON ST
Mailing Address - Street 2:#211
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4976
Mailing Address - Country:US
Mailing Address - Phone:831-477-6668
Mailing Address - Fax:
Practice Address - Street 1:200 WASHINGTON ST
Practice Address - Street 2:#211
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4976
Practice Address - Country:US
Practice Address - Phone:831-477-6668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20585103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00318497OtherRAILROAD MEDICARE
CAP00318497OtherRAILROAD MEDICARE
CA0PL205850Medicare ID - Type UnspecifiedMEDICARE