Provider Demographics
NPI:1356069348
Name:CARPENTIER, KATHLEEN GRACE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
Last Name:CARPENTIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11136 POINT SYLVAN CIR APT F
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6041
Mailing Address - Country:US
Mailing Address - Phone:954-410-3079
Mailing Address - Fax:
Practice Address - Street 1:11136 POINT SYLVAN CIR APT F
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-6041
Practice Address - Country:US
Practice Address - Phone:954-410-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW8280101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty