Provider Demographics
NPI:1336134717
Name:CARRACHER, PHILLIP V (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:V
Last Name:CARRACHER
Suffix:
Gender:M
Credentials:LCSW
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 495755
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-5755
Mailing Address - Country:US
Mailing Address - Phone:941-766-9555
Mailing Address - Fax:941-766-1511
Practice Address - Street 1:3191 HARBOR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6755
Practice Address - Country:US
Practice Address - Phone:941-766-9555
Practice Address - Fax:941-766-1511
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW56431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9367OtherBC
FLZ9367AMedicare ID - Type Unspecified