Provider Demographics
NPI:1689775512
Name:JAGANATH, MYTHILI (MFT)
Entity Type:Individual
Prefix:
First Name:MYTHILI
Middle Name:
Last Name:JAGANATH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23615 SPIRES ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-5244
Mailing Address - Country:US
Mailing Address - Phone:818-348-1436
Mailing Address - Fax:818-348-1436
Practice Address - Street 1:22048 SHERMAN WAY STE 307
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303
Practice Address - Country:US
Practice Address - Phone:818-348-1436
Practice Address - Fax:818-348-1436
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMF3157600Medicaid