Provider Demographics
NPI:1679833412
Name:DITOMASO, MARY E (LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:DITOMASO
Suffix:
Gender:F
Credentials:LMFT
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 702
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-0702
Mailing Address - Country:US
Mailing Address - Phone:805-441-8825
Mailing Address - Fax:805-543-1916
Practice Address - Street 1:11573 LOS OSOS VALLEY RD
Practice Address - Street 2:SUITE H
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6473
Practice Address - Country:US
Practice Address - Phone:805-441-8825
Practice Address - Fax:805-543-1916
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-28
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49069106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist