Provider Demographics
NPI:1497860829
Name:WHITE, MARY (LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 EASTGATE MALL
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92142-0398
Mailing Address - Country:US
Mailing Address - Phone:858-254-7243
Mailing Address - Fax:
Practice Address - Street 1:4445 EASTGATE MALL STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1979
Practice Address - Country:US
Practice Address - Phone:858-254-7243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2018-03-17
Deactivation Date:2013-07-01
Deactivation Code:
Reactivation Date:2017-08-11
Provider Licenses
StateLicense IDTaxonomies
171W00000X
CA95171106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171W00000XOther Service ProvidersContractor