Provider Demographics
NPI:1902028640
Name:SHOWALTER, CAROL A (DRPH, MFT)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:A
Last Name:SHOWALTER
Suffix:
Gender:F
Credentials:DRPH, MFT
Other - Prefix:DR
Other - First Name:CAROL
Other - Middle Name:SHOWALTER
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DRPH, MFT
Mailing Address - Street 1:PO BOX 825
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0266
Mailing Address - Country:US
Mailing Address - Phone:909-793-6177
Mailing Address - Fax:909-793-6177
Practice Address - Street 1:1512 BEL AIR CT
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-7117
Practice Address - Country:US
Practice Address - Phone:909-793-6177
Practice Address - Fax:909-793-6177
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC8850106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA149664OtherVALUE OPTIONS PROVIDER #