Provider Demographics
NPI:1245582121
Name:FOSSUM, MARY M
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ELLY
Other - Middle Name:M
Other - Last Name:FOSSUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, MS
Mailing Address - Street 1:1722 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2105
Mailing Address - Country:US
Mailing Address - Phone:916-716-0095
Mailing Address - Fax:916-973-9158
Practice Address - Street 1:1722 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2105
Practice Address - Country:US
Practice Address - Phone:916-716-0095
Practice Address - Fax:916-973-9158
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40137106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist