Provider Demographics
NPI:1699804658
Name:SELF, CAROL ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:SELF
Suffix:
Gender:F
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:PO BOX 975
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0975
Mailing Address - Country:US
Mailing Address - Phone:985-624-5466
Mailing Address - Fax:985-624-9839
Practice Address - Street 1:301 GIROD STREET
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448
Practice Address - Country:US
Practice Address - Phone:985-624-5466
Practice Address - Fax:985-624-9839
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
55489Medicare ID - Type Unspecified