Provider Demographics
NPI:1740772672
Name:PHIPPS, CARLETTE LATISH
Entity Type:Individual
Prefix:
First Name:CARLETTE
Middle Name:LATISH
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLETTE
Other - Middle Name:LATISH
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 CLAY BANK RD APT J3
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-2533
Mailing Address - Country:US
Mailing Address - Phone:707-580-3176
Mailing Address - Fax:
Practice Address - Street 1:1100 LINCOLN AVE STE 108
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-4908
Practice Address - Country:US
Practice Address - Phone:415-860-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB8228200106S00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician