Provider Demographics
NPI:1265579908
Name:RICHARDSON, MARY ISABEL (MFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ISABEL
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:M.
Other - Middle Name:ISABEL
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:30246 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8009
Mailing Address - Country:US
Mailing Address - Phone:951-244-4822
Mailing Address - Fax:951-679-8029
Practice Address - Street 1:30246 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-8009
Practice Address - Country:US
Practice Address - Phone:951-244-4822
Practice Address - Fax:951-679-8029
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28051106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist