Provider Demographics
NPI:1609600550
Name:WRIGHT, CARL-MARVIN KENNETH-ELIJAH
Entity type:Individual
Prefix:
First Name:CARL-MARVIN
Middle Name:KENNETH-ELIJAH
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 ORANGE AVE UNIT 316
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6034
Mailing Address - Country:US
Mailing Address - Phone:619-922-1178
Mailing Address - Fax:
Practice Address - Street 1:2423 HOOVER AVE
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-6619
Practice Address - Country:US
Practice Address - Phone:619-739-4569
Practice Address - Fax:877-602-5087
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician