Healthcare Provider Details

I. General information

NPI: 1871970996
Provider Name (Legal Business Name): MARY TENNES PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 CARLETON ST
BERKELEY CA
94704-3310
US

IV. Provider business mailing address

2417 CARLETON ST
BERKELEY CA
94704-3310
US

V. Phone/Fax

Practice location:
  • Phone: 510-653-1313
  • Fax:
Mailing address:
  • Phone: 510-653-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberPSY10410
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License NumberPSY10410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: