Provider Demographics
NPI:1316784523
Name:MELLBERG, CAROL LYNNE (MA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNNE
Last Name:MELLBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 KIMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-7017
Mailing Address - Country:US
Mailing Address - Phone:408-832-0439
Mailing Address - Fax:
Practice Address - Street 1:60 KIMBLE AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-7017
Practice Address - Country:US
Practice Address - Phone:408-832-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37666106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist