Provider Demographics
NPI:1235530924
Name:MAR, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MAR
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 1:6706 EMBARCADERO DRIVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:209-956-4240
Mailing Address - Fax:
Practice Address - Street 1:129 E CENTER ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4648
Practice Address - Country:US
Practice Address - Phone:209-239-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAIMF90081106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor