Provider Demographics
NPI:1942355268
Name:EDELSTEIN, MARY R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:R
Last Name:EDELSTEIN
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 1:1301 RALSTON AVE
Mailing Address - Street 2:BUILDING E, SUITE C
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-1960
Mailing Address - Country:US
Mailing Address - Phone:650-593-3274
Mailing Address - Fax:650-594-9299
Practice Address - Street 1:1301 RALSTON AVE
Practice Address - Street 2:BUILDING E, SUITE C
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-1960
Practice Address - Country:US
Practice Address - Phone:650-593-3274
Practice Address - Fax:650-594-9299
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13093103TA0700X, 103T00000X
CAPSY13093103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY130930Medicare ID - Type Unspecified