Provider Demographics
NPI:1013338938
Name:DR MARY ROLISON PHD
Entity Type:Organization
Organization Name:DR MARY ROLISON PHD
Other - Org Name:MARY ROLISON, PHD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROLISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:408-513-5107
Mailing Address - Street 1:2868 RUSTIC DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-1661
Mailing Address - Country:US
Mailing Address - Phone:408-513-5107
Mailing Address - Fax:
Practice Address - Street 1:18181 BUTTERFIELD BLVD
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-8108
Practice Address - Country:US
Practice Address - Phone:408-513-5107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS12823251B00000X, 251S00000X, 261QM0801X, 261QM0855X, 302R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305S00000XManaged Care OrganizationsPoint of Service