Provider Demographics
NPI:1083714208
Name:WOLOWICZ, MARY JO (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:WOLOWICZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27917 SAN NICOLAS DRIVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275
Mailing Address - Country:US
Mailing Address - Phone:310-377-7249
Mailing Address - Fax:310-378-3591
Practice Address - Street 1:655 DEEP VALLEY DRIVE
Practice Address - Street 2:SUITE 320
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275
Practice Address - Country:US
Practice Address - Phone:310-784-7249
Practice Address - Fax:310-378-3591
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25959106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist