Provider Demographics
NPI:1750899720
Name:FARRALES, CARLO MIGUEL (BS)
Entity type:Individual
Prefix:MR
First Name:CARLO
Middle Name:MIGUEL
Last Name:FARRALES
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3953 W 178TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-3826
Mailing Address - Country:US
Mailing Address - Phone:310-977-6766
Mailing Address - Fax:
Practice Address - Street 1:1230 ROSECRANS AVE STE 250
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2496
Practice Address - Country:US
Practice Address - Phone:310-406-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CARBT-17-30298106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst