Provider Demographics
NPI:1780774125
Name:DISHAROON, MARY NEWMAN (LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:NEWMAN
Last Name:DISHAROON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 WELLER ST
Mailing Address - Street 2:#4
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3183
Mailing Address - Country:US
Mailing Address - Phone:707-484-4541
Mailing Address - Fax:
Practice Address - Street 1:222 WELLER ST
Practice Address - Street 2:#4
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3183
Practice Address - Country:US
Practice Address - Phone:707-484-4541
Practice Address - Fax:707-658-1774
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38476106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist