Provider Demographics
NPI:1609041862
Name:CARBAJAL, JOSE I (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:I
Last Name:CARBAJAL
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 N PECAN ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-3502
Mailing Address - Country:US
Mailing Address - Phone:936-560-6855
Mailing Address - Fax:936-564-5232
Practice Address - Street 1:2214 N PECAN ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-3502
Practice Address - Country:US
Practice Address - Phone:936-560-6855
Practice Address - Fax:936-564-5232
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX409071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194247601Medicaid