Provider Demographics
NPI:1760822951
Name:PUNTENNEY, MARY ROSE
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ROSE
Last Name:PUNTENNEY
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 1:1963 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2394
Mailing Address - Country:US
Mailing Address - Phone:619-233-3432
Mailing Address - Fax:619-233-7022
Practice Address - Street 1:1963 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2394
Practice Address - Country:US
Practice Address - Phone:619-233-3432
Practice Address - Fax:619-233-7022
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF85220106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist