Provider Demographics
NPI:1275897266
Name:CARTER, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:CARTER
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 1:4748 N WATERFRONT WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2769
Mailing Address - Country:US
Mailing Address - Phone:208-994-8732
Mailing Address - Fax:
Practice Address - Street 1:4748 N WATERFRONT WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2769
Practice Address - Country:US
Practice Address - Phone:208-994-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1-12-10176103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst