Provider Demographics
NPI:1164509469
Name:FREIRE, MARY JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:FREIRE
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 1:2425 MISSION ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1620
Mailing Address - Country:US
Mailing Address - Phone:626-441-2910
Mailing Address - Fax:626-441-2485
Practice Address - Street 1:2425 MISSION ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-1620
Practice Address - Country:US
Practice Address - Phone:626-441-2910
Practice Address - Fax:626-441-2485
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11731103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PL117310OtherBLUE SHIELD PROVIDER NUMB
CAR15348Medicare UPIN
CACP11731Medicare ID - Type Unspecified