Provider Demographics
NPI:1003057860
Name:MIED, MARY LOU (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:MIED
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-0472
Mailing Address - Country:US
Mailing Address - Phone:925-942-0834
Mailing Address - Fax:925-942-0837
Practice Address - Street 1:919 VILLAGE CTR
Practice Address - Street 2:#9
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3598
Practice Address - Country:US
Practice Address - Phone:925-942-0834
Practice Address - Fax:925-942-0837
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21629103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist