Provider Demographics
NPI:1396030904
Name:CARBAJAL, RENEE MARIE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:CARBAJAL
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 1:1320 W KIMBERLY ST
Mailing Address - Street 2:APT # 230
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-2303
Mailing Address - Country:US
Mailing Address - Phone:520-289-9166
Mailing Address - Fax:520-296-8244
Practice Address - Street 1:1320 W KIMBERLY ST
Practice Address - Street 2:APT # 230
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-2303
Practice Address - Country:US
Practice Address - Phone:520-289-9166
Practice Address - Fax:520-296-8244
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2993258385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2993258OtherOLCR FOSTER CARE LICENSE