Basic Information
| Provider Information | |||||||||
| NPI: | 1952584013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRERA | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT INTERN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARRERA | ||||||||
| OtherFirstName: | JOHNNY | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | 54015 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8760 PARKCLIFF ST | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902425232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234810653 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10221 COMPTON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900022804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133855100 | ||||||||
| FaxNumber: | 3235661638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9999A | 01 | CA | DMH | OTHER |