Provider Demographics
NPI:1225596190
Name:ILIFF, MARY MICHELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELLE
Last Name:ILIFF
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ILIFF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 70104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92167-1104
Mailing Address - Country:US
Mailing Address - Phone:619-246-8560
Mailing Address - Fax:
Practice Address - Street 1:2333 1ST AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1540
Practice Address - Country:US
Practice Address - Phone:619-246-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104672106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist