Provider Demographics
NPI:1396462693
Name:AKSTIN, MARY I (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:I
Last Name:AKSTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W BONITA AVE APT 12A
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4585
Mailing Address - Country:US
Mailing Address - Phone:909-802-9548
Mailing Address - Fax:
Practice Address - Street 1:7365 CARNELIAN ST STE 202
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1157
Practice Address - Country:US
Practice Address - Phone:909-281-1557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW179781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical