Provider Demographics
NPI:1215019526
Name:KANZE, MARY ELLEN (MFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:KANZE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1194
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-1194
Mailing Address - Country:US
Mailing Address - Phone:530-621-9800
Mailing Address - Fax:
Practice Address - Street 1:768 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 304
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9260
Practice Address - Country:US
Practice Address - Phone:530-621-9800
Practice Address - Fax:530-621-9804
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT37852106H00000X
GAMFT000146106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist