Provider Demographics
NPI:1447621321
Name:BRETL, CARLY ROSE
Entity type:Individual
Prefix:
First Name:CARLY ROSE
Middle Name:
Last Name:BRETL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 WATER ST.
Mailing Address - Street 2:L2
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060
Mailing Address - Country:US
Mailing Address - Phone:831-200-3585
Mailing Address - Fax:831-459-0665
Practice Address - Street 1:550 WATER ST.
Practice Address - Street 2:L2
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060
Practice Address - Country:US
Practice Address - Phone:831-200-3585
Practice Address - Fax:831-459-0665
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-17
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT125744106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health