Provider Demographics
NPI:1497930895
Name:MCCONNELL, MARY JOAN (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOAN
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11260 WILBUR AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-2450
Mailing Address - Country:US
Mailing Address - Phone:818-773-8520
Mailing Address - Fax:818-341-2795
Practice Address - Street 1:11260 WILBUR AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-2450
Practice Address - Country:US
Practice Address - Phone:818-773-8520
Practice Address - Fax:818-341-2795
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT29889106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist