Provider Demographics
NPI:1629136676
Name:O'LEARY, MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10249
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-0249
Mailing Address - Country:US
Mailing Address - Phone:206-777-5726
Mailing Address - Fax:
Practice Address - Street 1:998 VINEYARD LN UNIT J301
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-3802
Practice Address - Country:US
Practice Address - Phone:206-777-5726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60025556103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40404226Medicaid