Provider Demographics
NPI:1649940495
Name:CUMMISKEY, MARY JO
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:CUMMISKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50855 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2891
Mailing Address - Country:US
Mailing Address - Phone:760-989-0384
Mailing Address - Fax:
Practice Address - Street 1:78160 MASTERS CIR
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7355
Practice Address - Country:US
Practice Address - Phone:760-989-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210183984103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool