Provider Demographics
NPI:1811462559
Name:MINCBERG, MALLORY HANNAH (LPCC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:HANNAH
Last Name:MINCBERG
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5406 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-4717
Mailing Address - Country:US
Mailing Address - Phone:171-350-4350
Mailing Address - Fax:
Practice Address - Street 1:5820 OBERLIN DR STE 112
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3743
Practice Address - Country:US
Practice Address - Phone:713-504-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73137101YM0800X
CA12810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health