Provider Demographics
NPI:1871369496
Name:CARPENTER, EMILY BROOKE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BROOKE
Last Name:CARPENTER
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 1:140 KING ARTHUR CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-1800
Mailing Address - Country:US
Mailing Address - Phone:303-551-5683
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5715
Practice Address - Country:US
Practice Address - Phone:904-206-7024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC615-202-04-625-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician