Basic Information
| Provider Information | |||||||||
| NPI: | 1366751166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERTZ | ||||||||
| FirstName: | KARLY | ||||||||
| MiddleName: | QUINN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074448293 | ||||||||
| FaxNumber: | 7074448298 | ||||||||
| Practice Location | |||||||||
| Address1: | 2257 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074448293 | ||||||||
| FaxNumber: | 7074448298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 118092 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.