Provider Demographics
NPI:1275008229
Name:CARR, DAVID ELLIS II
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ELLIS
Last Name:CARR
Suffix:II
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 1:3629 S D ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-6813
Mailing Address - Country:US
Mailing Address - Phone:253-798-6576
Mailing Address - Fax:
Practice Address - Street 1:3629 S D ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-6813
Practice Address - Country:US
Practice Address - Phone:253-798-6576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101YA0400XMedicaid