Provider Demographics
NPI:1780879809
Name:SPEASE, MARY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:SPEASE
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 1:5405 MOREHOUSE DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4722
Mailing Address - Country:US
Mailing Address - Phone:858-888-3261
Mailing Address - Fax:
Practice Address - Street 1:5405 MOREHOUSE DR
Practice Address - Street 2:SUITE 330
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4722
Practice Address - Country:US
Practice Address - Phone:858-888-3261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24780103T00000X, 103TA0400X, 103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling