Provider Demographics
NPI:1508941493
Name:ROTHERAM, MARY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:J
Last Name:ROTHERAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10920 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6502
Mailing Address - Country:US
Mailing Address - Phone:310-794-8278
Mailing Address - Fax:310-794-8297
Practice Address - Street 1:10920 WILSHIRE BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-6502
Practice Address - Country:US
Practice Address - Phone:310-794-8278
Practice Address - Fax:310-794-8297
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6558103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent