Provider Demographics
NPI:1346393626
Name:VANAMBURG, MARY ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:VANAMBURG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 EASTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1009
Mailing Address - Country:US
Mailing Address - Phone:323-226-8697
Mailing Address - Fax:323-226-2992
Practice Address - Street 1:1605 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1009
Practice Address - Country:US
Practice Address - Phone:323-226-8697
Practice Address - Fax:323-226-2992
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17148103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical