Provider Demographics
NPI:1235283631
Name:LIGHT, MARY T (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:LIGHT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20632 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-5239
Mailing Address - Country:US
Mailing Address - Phone:510-583-1295
Mailing Address - Fax:
Practice Address - Street 1:20284 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4312
Practice Address - Country:US
Practice Address - Phone:510-782-5164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35297106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist