Provider Demographics
NPI:1629317144
Name:MORTIMER, MARIA GABRIELLA
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:GABRIELLA
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:GIANNINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5603 BUTANO WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2605
Mailing Address - Country:US
Mailing Address - Phone:916-223-8287
Mailing Address - Fax:
Practice Address - Street 1:5603 BUTANO WAY
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2605
Practice Address - Country:US
Practice Address - Phone:916-223-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1118415103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst