Provider Demographics
NPI:1043316326
Name:POMETTA, CAROLYN J (LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:J
Last Name:POMETTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2626 N CALIFORNIA ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-467-4444
Mailing Address - Fax:209-467-0122
Practice Address - Street 1:2626 N CALIFORNIA ST
Practice Address - Street 2:SUITE E
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207
Practice Address - Country:US
Practice Address - Phone:209-467-4444
Practice Address - Fax:209-467-0122
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS169561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ44447ZMedicare ID - Type Unspecified