Provider Demographics
NPI:1316589823
Name:CARTER, RENICCA
Entity Type:Individual
Prefix:
First Name:RENICCA
Middle Name:
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4336 NORTH BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3920
Mailing Address - Country:US
Mailing Address - Phone:225-960-7419
Mailing Address - Fax:225-960-7421
Practice Address - Street 1:4336 NORTH BLVD STE 204
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3920
Practice Address - Country:US
Practice Address - Phone:225-960-7419
Practice Address - Fax:225-960-7421
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1952859472Medicaid