Provider Demographics
NPI:1497135248
Name:PELLINO-BENNER, MARYANN ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:ELIZABETH
Last Name:PELLINO-BENNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARYANN
Other - Middle Name:E
Other - Last Name:PELLINO BENNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:106 SAN JOSE AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2700
Mailing Address - Country:US
Mailing Address - Phone:650-355-9528
Mailing Address - Fax:650-355-1054
Practice Address - Street 1:106 SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2700
Practice Address - Country:US
Practice Address - Phone:650-355-9528
Practice Address - Fax:650-355-1054
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12726103TC0700X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis