Provider Demographics
NPI:1215430814
Name:CARRASCO, LUCY ANGELINA
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:ANGELINA
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:CAREFREE
Mailing Address - State:AZ
Mailing Address - Zip Code:85377-0910
Mailing Address - Country:US
Mailing Address - Phone:623-698-2322
Mailing Address - Fax:480-595-3175
Practice Address - Street 1:12558 N 76TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-4808
Practice Address - Country:US
Practice Address - Phone:623-698-2322
Practice Address - Fax:480-595-3175
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-10
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5328320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness