Provider Demographics
NPI:1225367899
Name:CARTER, SHIVAUN KATHLEEN
Entity Type:Individual
Prefix:DR
First Name:SHIVAUN
Middle Name:KATHLEEN
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SHIVOGN
Other - Middle Name:
Other - Last Name:DULEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2216 NEWPORT BLVD.
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-631-9009
Mailing Address - Fax:949-631-1984
Practice Address - Street 1:2216 NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:949-631-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist