Provider Demographics
NPI:1215407549
Name:CARRA, PHYLLIS RENEE (CATC NO 236831 I)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:RENEE
Last Name:CARRA
Suffix:
Gender:F
Credentials:CATC NO 236831 I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2772 S. MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706
Mailing Address - Country:US
Mailing Address - Phone:559-265-4800
Mailing Address - Fax:559-265-4823
Practice Address - Street 1:2772 S. MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:559-265-4823
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236831101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184991291Medicaid