Provider Demographics
NPI:1881040657
Name:MASSABAND, CAROLIN (MA)
Entity Type:Individual
Prefix:
First Name:CAROLIN
Middle Name:
Last Name:MASSABAND
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4820
Mailing Address - Country:US
Mailing Address - Phone:310-390-6612
Mailing Address - Fax:310-398-5690
Practice Address - Street 1:1540 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1514
Practice Address - Country:US
Practice Address - Phone:818-244-7257
Practice Address - Fax:818-243-5431
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA125454106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist