Provider Demographics
NPI:1790502680
Name:EARLY, CARMEN DIONNE (SUDRC 15389)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:DIONNE
Last Name:EARLY
Suffix:
Gender:F
Credentials:SUDRC 15389
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 ELMO DRIVE
Mailing Address - Street 2:4646
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:909-688-8003
Mailing Address - Fax:
Practice Address - Street 1:7806 SIERRA AVE APT 314
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3388
Practice Address - Country:US
Practice Address - Phone:909-688-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15398101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)