Provider Demographics
NPI:1740529189
Name:SANDERS, MARY KATHRYN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:SANDERS
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 1:5470 BALTIMORE DR
Mailing Address - Street 2:UNIT 5
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2033
Mailing Address - Country:US
Mailing Address - Phone:619-964-7588
Mailing Address - Fax:
Practice Address - Street 1:8775 AERO DR
Practice Address - Street 2:SUITE 132
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1792
Practice Address - Country:US
Practice Address - Phone:858-633-4102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33947101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health