Provider Demographics
NPI:1457738536
Name:GARRETT, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GARRETT
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 4334
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91617-0334
Mailing Address - Country:US
Mailing Address - Phone:818-561-1260
Mailing Address - Fax:
Practice Address - Street 1:2000 E 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3907
Practice Address - Country:US
Practice Address - Phone:714-989-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111022106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT111022OtherBOARD OF BEHAVIORAL SCIENCES