Provider Demographics
NPI:1972642858
Name:SULLIVAN-TANSEY, MARY L (RN, MFT, PSY D)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:SULLIVAN-TANSEY
Suffix:
Gender:F
Credentials:RN, MFT, PSY D
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:TANSEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, MFT, PSY D
Mailing Address - Street 1:12625 HESPERIA RD
Mailing Address - Street 2:SUITE 'F'
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7720
Mailing Address - Country:US
Mailing Address - Phone:909-337-4467
Mailing Address - Fax:909-337-4467
Practice Address - Street 1:12625 HESPERIA RD
Practice Address - Street 2:SUITE 'F'
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7720
Practice Address - Country:US
Practice Address - Phone:760-955-1777
Practice Address - Fax:760-955-2356
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 32835106H00000X
CA193750163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered163W00000XNursing Service ProvidersRegistered Nurse