Provider Demographics
NPI:1013067412
Name:RAE, MARY BRYCE (MFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BRYCE
Last Name:RAE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 S RANDOLPH AVE
Mailing Address - Street 2:STE. 160
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5739
Mailing Address - Country:US
Mailing Address - Phone:714-990-0909
Mailing Address - Fax:909-595-5701
Practice Address - Street 1:259 S RANDOLPH AVE
Practice Address - Street 2:STE. 160
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5739
Practice Address - Country:US
Practice Address - Phone:714-990-0909
Practice Address - Fax:909-595-5701
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23701106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist