Provider Demographics
NPI:1750517074
Name:CARR, CHARLES L (PHD, LISAC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:CARR
Suffix:
Gender:M
Credentials:PHD, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 N MASTICK WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1135
Mailing Address - Country:US
Mailing Address - Phone:520-394-4295
Mailing Address - Fax:
Practice Address - Street 1:1790 N MASTICK WAY
Practice Address - Street 2:SUITE D
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-1135
Practice Address - Country:US
Practice Address - Phone:520-394-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11766101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11766OtherARIZONA BOARD OF BEHAVIORAL HEALTH