Provider Demographics
NPI:1578902680
Name:STUART, MARRY JEAN
Entity Type:Individual
Prefix:
First Name:MARRY
Middle Name:JEAN
Last Name:STUART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14812 NOKOMIS RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-4809
Mailing Address - Country:US
Mailing Address - Phone:760-912-2055
Mailing Address - Fax:
Practice Address - Street 1:39959 SIERRA HWY STE 150
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-3320
Practice Address - Country:US
Practice Address - Phone:213-332-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW779911041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program