Provider Demographics
NPI:1144344136
Name:CARPENTER, AUSTIN ABBOTT JR (PHD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:ABBOTT
Last Name:CARPENTER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:AVENAL
Mailing Address - State:CA
Mailing Address - Zip Code:93204-0249
Mailing Address - Country:US
Mailing Address - Phone:443-554-6360
Mailing Address - Fax:559-386-1085
Practice Address - Street 1:645 W HARDING WAY
Practice Address - Street 2:SUTIE 2
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5688
Practice Address - Country:US
Practice Address - Phone:209-465-4955
Practice Address - Fax:559-386-1085
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16361103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 163610Medicaid
CAPSY 163610Medicaid