Provider Demographics
NPI:1215215348
Name:MERCHANT, MARY E (PSY D, MFT, LEP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MERCHANT
Suffix:
Gender:F
Credentials:PSY D, MFT, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11560 MAYNARD AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-3380
Mailing Address - Country:US
Mailing Address - Phone:714-955-1376
Mailing Address - Fax:
Practice Address - Street 1:2222 MARTIN
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1458
Practice Address - Country:US
Practice Address - Phone:714-955-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP 2911103TS0200X
CAMFC 32490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool