Provider Demographics
NPI:1619205606
Name:THEODORE, CARLINE (MA, EDM)
Entity Type:Individual
Prefix:MS
First Name:CARLINE
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:MA, EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 135TH ST
Mailing Address - Street 2:#5C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W 135TH ST
Practice Address - Street 2:#5C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2731
Practice Address - Country:US
Practice Address - Phone:212-283-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health