Provider Demographics
NPI:1689907073
Name:CARLTON, DEBERA (PSR)
Entity Type:Individual
Prefix:MRS
First Name:DEBERA
Middle Name:
Last Name:CARLTON
Suffix:
Gender:F
Credentials:PSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 SOUTH LOS LENTES RD.
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-0518
Mailing Address - Country:US
Mailing Address - Phone:505-865-3350
Mailing Address - Fax:505-865-4739
Practice Address - Street 1:428 SOUTH LOS LENTES RD
Practice Address - Street 2:428 SOUTH LOS LENTES RD
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-3350
Practice Address - Fax:505-865-4739
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2016-03-22
Deactivation Date:2016-03-21
Deactivation Code:
Reactivation Date:2016-03-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850294695OtherTAX ID