Provider Demographics
NPI:1679905632
Name:MYERS, CARRIE (BCABA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 6TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4383
Mailing Address - Country:US
Mailing Address - Phone:800-515-5016
Mailing Address - Fax:
Practice Address - Street 1:94-849 LUMIAINA ST UNIT 201
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-5677
Practice Address - Country:US
Practice Address - Phone:800-515-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBCABA: 0-13-5507103K00000X
1-14-15072103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-14-15072OtherBACB