Provider Demographics
NPI:1013205277
Name:BRONSTEIN, MARA LENOX (PSYD)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:LENOX
Last Name:BRONSTEIN
Suffix:
Gender:F
Credentials:PSYD
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 3763
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-0763
Mailing Address - Country:US
Mailing Address - Phone:650-231-4835
Mailing Address - Fax:
Practice Address - Street 1:881 FREMONT AVE
Practice Address - Street 2:SUITE B8
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5697
Practice Address - Country:US
Practice Address - Phone:650-231-4835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical