Basic Information
| Provider Information | |||||||||
| NPI: | 1205493301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZELAYA | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14600 SHERMAN WAY STE 100D | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914052283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183746901 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14600 SHERMAN WAY STE 100D | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914052283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183746901 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2019 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5636 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 10528 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.