Provider Demographics
NPI:1104978113
Name:LOREDO, CARLOS MIGUEL (PHD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:MIGUEL
Last Name:LOREDO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 MONTCLAIRE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3909
Mailing Address - Country:US
Mailing Address - Phone:512-443-0190
Mailing Address - Fax:512-326-4818
Practice Address - Street 1:2111 MONTCLAIRE ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-3909
Practice Address - Country:US
Practice Address - Phone:512-443-0190
Practice Address - Fax:512-326-4818
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1637103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist