Provider Demographics
NPI:1689913634
Name:CARTER, MARY CARMICHAEL
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CARMICHAEL
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-6718
Mailing Address - Country:US
Mailing Address - Phone:469-693-9354
Mailing Address - Fax:817-255-7166
Practice Address - Street 1:1518 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-6718
Practice Address - Country:US
Practice Address - Phone:469-693-9354
Practice Address - Fax:817-255-7166
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52414104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker