Provider Demographics
NPI:1336438498
Name:MALLATT-GROW, CYNTHIA S (LMFT #85046)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:S
Last Name:MALLATT-GROW
Suffix:
Gender:F
Credentials:LMFT #85046
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34117 VILLAGE 34
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-7251
Mailing Address - Country:US
Mailing Address - Phone:352-242-8767
Mailing Address - Fax:
Practice Address - Street 1:766 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1702
Practice Address - Country:US
Practice Address - Phone:818-676-1540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85046106H00000X
FL2636106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist