Provider Demographics
NPI:1063867208
Name:YERDON, CARRIE (LMFT)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:YERDON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:DIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT, IMFT
Mailing Address - Street 1:PO BOX 231104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-1104
Mailing Address - Country:US
Mailing Address - Phone:619-335-5638
Mailing Address - Fax:
Practice Address - Street 1:2602 MOBLEY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3031
Practice Address - Country:US
Practice Address - Phone:619-335-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF83555106H00000X
103K00000X
CALMFT114924106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN