Provider Demographics
NPI:1164700761
Name:CARBAJAL, PAUL (PSYD)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:CARBAJAL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GRAND AVE.
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93407
Mailing Address - Country:US
Mailing Address - Phone:805-369-1319
Mailing Address - Fax:
Practice Address - Street 1:1530 MONTEREY ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2969
Practice Address - Country:US
Practice Address - Phone:805-369-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-30
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY28616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program