Provider Demographics
NPI:1164794145
Name:MAZAHERI, MARY M (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MAZAHERI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARYAM
Other - Middle Name:MEHRAK
Other - Last Name:MAZAHERI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1872 AVENIDA LA POSTA
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-7113
Mailing Address - Country:US
Mailing Address - Phone:408-513-5135
Mailing Address - Fax:
Practice Address - Street 1:312 S CEDROS AVE
Practice Address - Street 2:STE 150
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1942
Practice Address - Country:US
Practice Address - Phone:760-297-7335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
CA24102103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN