Provider Demographics
NPI:1053693267
Name:CARMONA, JUAN L (LCSW)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:L
Last Name:CARMONA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 JEFFERSON AVE.
Mailing Address - Street 2:SUITE #195
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2350
Mailing Address - Country:US
Mailing Address - Phone:916-403-2970
Mailing Address - Fax:916-204-5255
Practice Address - Street 1:500 JEFFERSON AVE.
Practice Address - Street 2:SUITE #195
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2350
Practice Address - Country:US
Practice Address - Phone:916-403-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CALCSW760961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker