Provider Demographics
NPI:1326362443
Name:CHAVEZ, CARL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:CHAVEZ
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:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93061
Mailing Address - Country:US
Mailing Address - Phone:805-242-8399
Mailing Address - Fax:
Practice Address - Street 1:950 COUNTY SQUARE DRIVE SUITE 112
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-242-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126443106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist