Provider Demographics
NPI:1003171893
Name:MASCARDO, M. THERESE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:M. THERESE
Middle Name:
Last Name:MASCARDO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARIA
Other - Middle Name:THERESE
Other - Last Name:MASCARDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:1619 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-4015
Mailing Address - Country:US
Mailing Address - Phone:949-682-9474
Mailing Address - Fax:
Practice Address - Street 1:1619 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4015
Practice Address - Country:US
Practice Address - Phone:949-682-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25022103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical