Provider Demographics
NPI:1508903618
Name:EWERT, MARY J (DMH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:EWERT
Suffix:
Gender:F
Credentials:DMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2186 GEARY BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2186 GEARY BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3455
Practice Address - Country:US
Practice Address - Phone:415-922-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11635103T00000X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis