Provider Demographics
NPI:1316979818
Name:PURVIANCE, CARLTON W (PHD)
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:W
Last Name:PURVIANCE
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 1:1416 TENNESSEE ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4647
Mailing Address - Country:US
Mailing Address - Phone:707-552-6397
Mailing Address - Fax:707-647-1305
Practice Address - Street 1:1416 TENNESSEE ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4647
Practice Address - Country:US
Practice Address - Phone:707-552-6397
Practice Address - Fax:707-647-1305
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4081103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR25204Medicare UPIN
CAOOPL40810Medicare ID - Type Unspecified