Provider Demographics
NPI:1669241881
Name:CARLOS, MICHELLE ROSEMARY (LPT)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ROSEMARY
Last Name:CARLOS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:ROSEMARY
Other - Last Name:COMEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:9890 COUNTY FARM RD STE 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3678
Mailing Address - Country:US
Mailing Address - Phone:951-509-2499
Mailing Address - Fax:
Practice Address - Street 1:9890 COUNTY FARM RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3678
Practice Address - Country:US
Practice Address - Phone:951-509-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36916167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician