Provider Demographics
NPI:1598052912
Name:STANLEY, MARY RUTH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RUTH
Last Name:STANLEY
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 1:16 BROMPTON CT
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6558
Mailing Address - Country:US
Mailing Address - Phone:951-440-6532
Mailing Address - Fax:
Practice Address - Street 1:255 TERRACINA BLVD
Practice Address - Street 2:SUITE # 204
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-792-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMCF 48280106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist