Provider Demographics
NPI:1194891127
Name:CARNOSSO, DEBRA ANNE (LCSW-R AND LISW-CP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANNE
Last Name:CARNOSSO
Suffix:
Gender:F
Credentials:LCSW-R AND LISW-CP
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:ANNE
Other - Last Name:DOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:361 VINTAGE CIR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-7132
Mailing Address - Country:US
Mailing Address - Phone:315-405-5703
Mailing Address - Fax:
Practice Address - Street 1:901 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3722
Practice Address - Country:US
Practice Address - Phone:843-448-4820
Practice Address - Fax:843-448-9875
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105771041C0700X
NY0754941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA1266Medicare PIN