Provider Demographics
NPI:1699918367
Name:DE MELLO, CARLA AMARAL GONCALVES (MFT)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:AMARAL GONCALVES
Last Name:DE MELLO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1379 JOYCE ST
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4520
Mailing Address - Country:US
Mailing Address - Phone:415-342-6260
Mailing Address - Fax:
Practice Address - Street 1:1748 NOVATO BLVD STE 210
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-7855
Practice Address - Country:US
Practice Address - Phone:415-342-6260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA86513106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health