Provider Demographics
NPI:1669744173
Name:LARENAS, MARY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:LARENAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 THORNTON AVE # 54
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7400
Mailing Address - Country:US
Mailing Address - Phone:510-797-4911
Mailing Address - Fax:
Practice Address - Street 1:39198 STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1436
Practice Address - Country:US
Practice Address - Phone:510-797-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB35897103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical