Provider Demographics
NPI:1598364879
Name:HARLEY, MARY BARRON
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BARRON
Last Name:HARLEY
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 1:180 CALLE CUERVO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2432
Mailing Address - Country:US
Mailing Address - Phone:949-394-5494
Mailing Address - Fax:
Practice Address - Street 1:657 CAMINO DE LOS MARES STE 241
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2811
Practice Address - Country:US
Practice Address - Phone:949-394-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA48318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty