Provider Demographics
NPI:1801149299
Name:ROBERTS, MARY DANIELSON
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DANIELSON
Last Name:ROBERTS
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 1:906 CALLE VENEZIA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-6038
Mailing Address - Country:US
Mailing Address - Phone:949-449-9550
Mailing Address - Fax:
Practice Address - Street 1:3150 PIO PICO DR STE 105
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1951
Practice Address - Country:US
Practice Address - Phone:949-207-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT91518106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist