Provider Demographics
NPI:1386812170
Name:ADKISSON, CAROL ROSE (MA, MFT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ROSE
Last Name:ADKISSON
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:ROSE
Other - Last Name:MURARIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:17057 FOOTHILL BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3523
Mailing Address - Country:US
Mailing Address - Phone:909-266-7009
Mailing Address - Fax:909-693-3177
Practice Address - Street 1:17057 FOOTHILL BLVD STE 205
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3523
Practice Address - Country:US
Practice Address - Phone:909-266-7009
Practice Address - Fax:909-693-3177
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83484106H00000X
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty