Provider Demographics
NPI:1336487248
Name:BOATNER, CARLA MARIE (MFTI)
Entity Type:Individual
Prefix:MISS
First Name:CARLA
Middle Name:MARIE
Last Name:BOATNER
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 CUMMINS DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-6400
Mailing Address - Country:US
Mailing Address - Phone:209-576-1750
Mailing Address - Fax:
Practice Address - Street 1:1620 CUMMINS DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-6400
Practice Address - Country:US
Practice Address - Phone:209-576-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73038106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist