Provider Demographics
NPI:1316203904
Name:MAHABALI, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MAHABALI
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:PO BOX 915
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-0915
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVENUE, 3RD FLOOR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-08
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF64344106H00000X
CA84057106H00000X
CA00232920101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist