Provider Demographics
NPI:1225420201
Name:CARSON, ANTHONY SHAWN (LMFT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:SHAWN
Last Name:CARSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30300 ANTELOPE RD APT 828
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-9467
Mailing Address - Country:US
Mailing Address - Phone:909-708-5849
Mailing Address - Fax:
Practice Address - Street 1:1400 E COOLEY DR STE 200A
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3939
Practice Address - Country:US
Practice Address - Phone:909-295-5295
Practice Address - Fax:909-295-5295
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF81612101YM0800X
CA111892106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health