Provider Demographics
NPI:1518011725
Name:MIRELL, MARY MARGARET (MFT 25701 MA DEGREE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:MIRELL
Suffix:
Gender:F
Credentials:MFT 25701 MA DEGREE
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:MIRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA DEGREE
Mailing Address - Street 1:4609 ALLA RD
Mailing Address - Street 2:#4
Mailing Address - City:MARINA DEL RAY
Mailing Address - State:CA
Mailing Address - Zip Code:90292
Mailing Address - Country:US
Mailing Address - Phone:310-306-6986
Mailing Address - Fax:
Practice Address - Street 1:610 SANTA MONICA BLVD
Practice Address - Street 2:#218
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1632
Practice Address - Country:US
Practice Address - Phone:310-394-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT25701106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist