Provider Demographics
NPI:1114320603
Name:CAROLLO, DONNA (MFT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:CAROLLO
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 1:657 CAMINO DE LOS MARES STE 241
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2811
Mailing Address - Country:US
Mailing Address - Phone:949-547-2957
Mailing Address - Fax:
Practice Address - Street 1:657 CAMINO DE LOS MARES STE 241
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2811
Practice Address - Country:US
Practice Address - Phone:949-547-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC80214106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist