Provider Demographics
NPI:1811021702
Name:NYCUM, MARY ANN (MA MFT)
Entity Type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:
Last Name:NYCUM
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W VISTA WAY
Mailing Address - Street 2:#407
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5732
Mailing Address - Country:US
Mailing Address - Phone:760-758-1092
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY
Practice Address - Street 2:#407
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5732
Practice Address - Country:US
Practice Address - Phone:760-758-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist