Basic Information
| Provider Information | |||||||||
| NPI: | 1720117476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | TARRY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA,MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 838 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900211028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136238446 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 838 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900211028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136238446 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFCC 49832 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.