Provider Demographics
NPI:1932456316
Name:MERCADO, CARMEN ANA (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:ANA
Last Name:MERCADO
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 FRANKLIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2618
Mailing Address - Country:US
Mailing Address - Phone:310-310-8822
Mailing Address - Fax:
Practice Address - Street 1:1910 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-1220
Practice Address - Country:US
Practice Address - Phone:213-342-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7782Medicaid