Provider Demographics
NPI:1164980165
Name:FORTENBERRY, CARLTON
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 OBISPO AVE.
Mailing Address - Street 2:UNIT 1
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804
Mailing Address - Country:US
Mailing Address - Phone:858-336-8636
Mailing Address - Fax:
Practice Address - Street 1:775 OBISPO AVE.
Practice Address - Street 2:UNIT 1
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804
Practice Address - Country:US
Practice Address - Phone:858-336-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician