Provider Demographics
NPI:1386161164
Name:CHEN, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:CHEN
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 1:5734 CARIBBEAN CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-5633
Mailing Address - Country:US
Mailing Address - Phone:209-635-0956
Mailing Address - Fax:
Practice Address - Street 1:5637 N PERSHING AVE STE B7
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4955
Practice Address - Country:US
Practice Address - Phone:209-635-0956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-20-43586103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst