Basic Information
| Provider Information | |||||||||
| NPI: | 1821451709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51322 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421025622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707778283 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 CANAL ST | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313224085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129881444 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2016 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-16164 | GA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 110026265E | 05 | MA | MEDICAID |