Provider Demographics
NPI:1417376641
Name:BAINS-FORT, MARY DENISE (LMFT, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:DENISE
Last Name:BAINS-FORT
Suffix:
Gender:F
Credentials:LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 MONTEREY ST
Mailing Address - Street 2:#215
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-4637
Mailing Address - Country:US
Mailing Address - Phone:831-586-0034
Mailing Address - Fax:
Practice Address - Street 1:910 MONTEREY ST
Practice Address - Street 2:#215
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-4637
Practice Address - Country:US
Practice Address - Phone:831-586-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53021106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist