Provider Demographics
NPI:1154832285
Name:DAFESH, CAROL ELLEN (LMFT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ELLEN
Last Name:DAFESH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:RIVINGTON
Other - Last Name:DAFESH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-0171
Mailing Address - Country:US
Mailing Address - Phone:310-741-2231
Mailing Address - Fax:
Practice Address - Street 1:2401 PACIFIC COAST HWY STE 104
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2734
Practice Address - Country:US
Practice Address - Phone:310-741-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44108106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist