Provider Demographics
NPI:1548682628
Name:MALLORY, KAREN LYNN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LYNN
Last Name:MALLORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:LYNN
Other - Last Name:NAVACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3941 TERNEZ DR
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-9765
Mailing Address - Country:US
Mailing Address - Phone:805-990-3498
Mailing Address - Fax:
Practice Address - Street 1:450 ROSEWOOD AVE STE 215
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-5914
Practice Address - Country:US
Practice Address - Phone:805-482-1265
Practice Address - Fax:805-389-5295
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-M1307251019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)