Provider Demographics
NPI:1841477262
Name:HERTENSTEIN, CARL CHRISTIAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:CHRISTIAN
Last Name:HERTENSTEIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BRANDIWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2242
Mailing Address - Country:US
Mailing Address - Phone:386-490-5745
Mailing Address - Fax:386-788-3600
Practice Address - Street 1:3256 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 1100
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:407-416-5611
Practice Address - Fax:386-788-3600
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 2941101YA0400X, 101YM0800X, 101YP1600X, 101YP2500X, 104100000X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104100000XOtherTAXONOMY CODE
FLAK122Medicare PIN