Provider Demographics
NPI:1497823298
Name:CARTER, LORALEE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:LORALEE
Middle Name:ANN
Last Name:CARTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MARK WEST SPRINGS RD
Mailing Address - Street 2:SUITE 400C
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1457
Mailing Address - Country:US
Mailing Address - Phone:707-396-4692
Mailing Address - Fax:
Practice Address - Street 1:50 MARK WEST SPRINGS RD
Practice Address - Street 2:SUITE 400C
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1457
Practice Address - Country:US
Practice Address - Phone:707-396-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152121041C0700X
WI27071041C0700X
CA664071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN858247500Medicaid
MN024K8CAOtherBLUE CROSS BLUE SHIELD
MN800001283Medicare PIN
MN024K8CAOtherBLUE CROSS BLUE SHIELD