Provider Demographics
NPI:1649705369
Name:CAMARENA, CARLOS CEASAR
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:CEASAR
Last Name:CAMARENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9540 CENTER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5840
Mailing Address - Country:US
Mailing Address - Phone:909-980-2789
Mailing Address - Fax:
Practice Address - Street 1:9540 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5840
Practice Address - Country:US
Practice Address - Phone:909-980-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI3123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health