Basic Information
| Provider Information | |||||||||
| NPI: | 1780837195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARBAJAL | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | GISELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CEJA DE ANDA | ||||||||
| OtherFirstName: | EMMA | ||||||||
| OtherMiddleName: | GISELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1801 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910102686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 51906 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.