Provider Demographics
NPI:1053328823
Name:MALIK, MARY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:MALIK
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 1:1110 CALIFORNIA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2970
Mailing Address - Country:US
Mailing Address - Phone:805-541-2490
Mailing Address - Fax:
Practice Address - Street 1:1110 CALIFORNIA BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2970
Practice Address - Country:US
Practice Address - Phone:805-541-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL198610OtherBLUE SHIELD OF CA PIN
CACP19861Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER