Provider Demographics
NPI:1518066125
Name:CARLOS, OCTAVIA M (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:OCTAVIA
Middle Name:M
Last Name:CARLOS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN
Mailing Address - Street 2:SUITE 139A1
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:301-322-3016
Mailing Address - Fax:301-925-1839
Practice Address - Street 1:1300 MERCANTILE LN
Practice Address - Street 2:SUITE 139A1
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:301-322-3016
Practice Address - Fax:301-925-1839
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD059951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical