Provider Demographics
NPI:1053988089
Name:CARMONA-CARLO, CHRISTIAN JAVIER
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:JAVIER
Last Name:CARMONA-CARLO
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 1:3350 BRECKINRIDGE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4959
Mailing Address - Country:US
Mailing Address - Phone:770-962-8396
Mailing Address - Fax:
Practice Address - Street 1:3350 BRECKINRIDGE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4959
Practice Address - Country:US
Practice Address - Phone:770-962-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012123101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional