Provider Demographics
NPI:1801086749
Name:GEORGIO-LAWLOR, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GEORGIO-LAWLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:GEORGIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 CARMEN LN
Mailing Address - Street 2:201
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7769
Mailing Address - Country:US
Mailing Address - Phone:805-739-8707
Mailing Address - Fax:
Practice Address - Street 1:212 CARMEN LN
Practice Address - Street 2:201
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7769
Practice Address - Country:US
Practice Address - Phone:805-739-8707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53643106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53643OtherLICENSE
1952589228OtherCARES CRISIS RESIDENTIAL