Basic Information
Provider Information | |||||||||
NPI: | 1891938635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCRAE | ||||||||
FirstName: | MARY ELLEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CLAYTON | ||||||||
OtherFirstName: | MARY ELLEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMFT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 99 | ||||||||
Address2: |   | ||||||||
City: | MARIPOSA | ||||||||
State: | CA | ||||||||
PostalCode: | 953380099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2099662000 | ||||||||
FaxNumber: | 2099668251 | ||||||||
Practice Location | |||||||||
Address1: | 5078 BULLION STREET | ||||||||
Address2: | SUITE 1 | ||||||||
City: | MARIPOSA | ||||||||
State: | CA | ||||||||
PostalCode: | 95338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2097423498 | ||||||||
FaxNumber: | 2099663925 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2009 | ||||||||
LastUpdateDate: | 01/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 52655 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.