Provider Demographics
NPI:1548655772
Name:CARBERRY, MYLENE LOUISE (LMFT)
Entity type:Individual
Prefix:MS
First Name:MYLENE
Middle Name:LOUISE
Last Name:CARBERRY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 S CANFIELD AVE
Mailing Address - Street 2:APT. 11
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-4368
Mailing Address - Country:US
Mailing Address - Phone:310-621-1087
Mailing Address - Fax:
Practice Address - Street 1:3145 S CANFIELD AVE
Practice Address - Street 2:APT. 11
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-4368
Practice Address - Country:US
Practice Address - Phone:310-621-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82472106H00000X
CA103558106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist