Provider Demographics
NPI:1083879506
Name:MACILVAINE, MARY LOU (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:MACILVAINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:MACILVAINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:4313 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2052
Mailing Address - Country:US
Mailing Address - Phone:619-501-0334
Mailing Address - Fax:
Practice Address - Street 1:4313 RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2052
Practice Address - Country:US
Practice Address - Phone:619-501-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14409103TC2200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth