Provider Demographics
NPI:1992685614
Name:CARBAJAL, ATHENA COURTNEY
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:COURTNEY
Last Name:CARBAJAL
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 1:5850 GRANITE PKWY STE 600
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6753
Mailing Address - Country:US
Mailing Address - Phone:469-694-1754
Mailing Address - Fax:
Practice Address - Street 1:1304 E MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-3202
Practice Address - Country:US
Practice Address - Phone:805-941-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY5736547106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician