Provider Demographics
NPI:1679946479
Name:CARUTH-IACONO, CHARISSE MARIE (LAADC)
Entity Type:Individual
Prefix:MRS
First Name:CHARISSE
Middle Name:MARIE
Last Name:CARUTH-IACONO
Suffix:
Gender:F
Credentials:LAADC
Other - Prefix:MISS
Other - First Name:CHARISSE
Other - Middle Name:MARIE
Other - Last Name:CARUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCAS
Mailing Address - Street 1:1625 SCHRADER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:213-466-5042
Mailing Address - Fax:
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:213-466-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARALR8960418390200000X
NCLCAS-21587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL