Provider Demographics
NPI:1902228000
Name:MITOCK, DANIELLE (LICENSED MFT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:MITOCK
Suffix:
Gender:F
Credentials:LICENSED MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14515 HAMLIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1608
Mailing Address - Country:US
Mailing Address - Phone:818-989-7475
Mailing Address - Fax:818-908-2434
Practice Address - Street 1:14515 HAMLIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1608
Practice Address - Country:US
Practice Address - Phone:818-989-7475
Practice Address - Fax:818-908-2434
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112423106H00000X
CA75781106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7667OtherMEDI-CAL