Provider Demographics
NPI:1538784962
Name:CARREON, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CARREON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 E TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-3328
Mailing Address - Country:US
Mailing Address - Phone:213-253-2677
Mailing Address - Fax:
Practice Address - Street 1:351 E TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3328
Practice Address - Country:US
Practice Address - Phone:213-253-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2024-03-06
Deactivation Date:2021-09-24
Deactivation Code:
Reactivation Date:2021-10-07
Provider Licenses
StateLicense IDTaxonomies
CA102127101YM0800X, 1041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health