Provider Demographics
NPI:1720537236
Name:CARRANCO, CLARISVEL
Entity Type:Individual
Prefix:
First Name:CLARISVEL
Middle Name:
Last Name:CARRANCO
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 1:2425 E SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6675
Mailing Address - Country:US
Mailing Address - Phone:817-442-0222
Mailing Address - Fax:
Practice Address - Street 1:2425 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6675
Practice Address - Country:US
Practice Address - Phone:817-442-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician