Provider Demographics
NPI:1013226232
Name:DUNHAM, MARY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:ANN
Other - Last Name:DUNHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13952 BORA BORA WAY APT 203F
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6823
Mailing Address - Country:US
Mailing Address - Phone:310-823-3897
Mailing Address - Fax:
Practice Address - Street 1:444 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2917
Practice Address - Country:US
Practice Address - Phone:818-552-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 112831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical