Provider Demographics
NPI:1841836244
Name:TICHACEK, MARY J (RN, PMHNP, PMHCNS)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:TICHACEK
Suffix:
Gender:F
Credentials:RN, PMHNP, PMHCNS
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:TICHACEK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7770 REGENTS ROAD
Mailing Address - Street 2:NO 113514
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122
Mailing Address - Country:US
Mailing Address - Phone:858-245-1195
Mailing Address - Fax:760-355-0161
Practice Address - Street 1:2417 MARSHALL AVE STE 1
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9401
Practice Address - Country:US
Practice Address - Phone:858-245-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202048163W00000X
CA207364S00000X
CA95024198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist