Provider Demographics
NPI:1194276006
Name:MENDEZ, CARLENE MIRAN
Entity type:Individual
Prefix:
First Name:CARLENE
Middle Name:MIRAN
Last Name:MENDEZ
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 1:515 COLUMBIA AVE # 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1209
Mailing Address - Country:US
Mailing Address - Phone:213-249-9388
Mailing Address - Fax:626-961-1810
Practice Address - Street 1:515 COLUMBIA AVE # 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1209
Practice Address - Country:US
Practice Address - Phone:213-249-9388
Practice Address - Fax:626-961-1810
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1224970316101YA0400X
CA2013518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)