Provider Demographics
NPI:1225297195
Name:ENTEZAR, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ENTEZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W FLORIDA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4628
Mailing Address - Country:US
Mailing Address - Phone:951-658-7122
Mailing Address - Fax:951-658-7140
Practice Address - Street 1:1300 W FLORIDA AVE STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4628
Practice Address - Country:US
Practice Address - Phone:951-658-7122
Practice Address - Fax:951-658-7140
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
130593106H00000X
CA130593101YP2500X
91016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional