Provider Demographics
NPI:1578104782
Name:CARBAJAL, MINERVA A (BCBA)
Entity Type:Individual
Prefix:
First Name:MINERVA
Middle Name:A
Last Name:CARBAJAL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5658 SEPULVEDA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2951
Mailing Address - Country:US
Mailing Address - Phone:818-455-3576
Mailing Address - Fax:
Practice Address - Street 1:5658 SEPULVEDA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-2951
Practice Address - Country:US
Practice Address - Phone:818-455-3576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-37531103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst