Provider Demographics
NPI:1942919717
Name:DUFFY, MARYANNE (MFT #26013)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:DUFFY
Suffix:
Gender:F
Credentials:MFT #26013
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4537 SHADEWAY RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-2833
Mailing Address - Country:US
Mailing Address - Phone:562-241-9721
Mailing Address - Fax:
Practice Address - Street 1:4537 SHADEWAY RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-2833
Practice Address - Country:US
Practice Address - Phone:562-241-9721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT26013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2J05-D28-UN79Medicaid
CAE0627975OtherDRIVERS LICENSE