Provider Demographics
NPI:1720141435
Name:CARCELLI, LAWRENCE ANTHONY (PHD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ANTHONY
Last Name:CARCELLI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150307
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-317-1884
Mailing Address - Fax:801-479-8286
Practice Address - Street 1:425 E 5350 S
Practice Address - Street 2:370
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6946
Practice Address - Country:US
Practice Address - Phone:801-317-1884
Practice Address - Fax:801-479-8286
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT871138852501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR34537Medicare UPIN