Provider Demographics
NPI:1366656589
Name:BECKER, MARY LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:BECKER
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 1:625 FAIR OAKS AVE STE 374
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5814
Mailing Address - Country:US
Mailing Address - Phone:626-403-0959
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE STE 374
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-5814
Practice Address - Country:US
Practice Address - Phone:626-403-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP 13404Medicare ID - Type Unspecified