Provider Demographics
NPI:1972178101
Name:CHEN, CARRIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CHEN
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 1:5530 CORBIN AVE STE 221
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6095
Mailing Address - Country:US
Mailing Address - Phone:818-600-8758
Mailing Address - Fax:833-728-0328
Practice Address - Street 1:5530 CORBIN AVE STE 221
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-6095
Practice Address - Country:US
Practice Address - Phone:818-600-8758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-18352106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0Medicaid