Provider Demographics
NPI:1730220039
Name:CARPER, JOHN MARK (EDD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:CARPER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:J MARK
Other - Middle Name:
Other - Last Name:CARPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:115 SUMMIT AVE
Mailing Address - Street 2:NO. 3
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-1087
Mailing Address - Country:US
Mailing Address - Phone:617-846-5383
Mailing Address - Fax:617-846-1650
Practice Address - Street 1:115 SUMMIT AVE
Practice Address - Street 2:NO. 3
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-1087
Practice Address - Country:US
Practice Address - Phone:617-846-5383
Practice Address - Fax:617-846-1650
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3856103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3856OtherLIC.. (PSYCHOL.PROVIDER)
MA0516678Medicaid