Provider Demographics
NPI:1790801397
Name:BAUMAN, MARY RYERSON (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RYERSON
Last Name:BAUMAN
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 1:3168 OAKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1743
Mailing Address - Country:US
Mailing Address - Phone:818-779-5273
Mailing Address - Fax:323-851-2350
Practice Address - Street 1:13130 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91401-6037
Practice Address - Country:US
Practice Address - Phone:818-779-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17065103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling