Healthcare Provider Details

I. General information

NPI: 1649940495
Provider Name (Legal Business Name): MARY JO CUMMISKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78160 MASTERS CIR
LA QUINTA CA
92253-7355
US

IV. Provider business mailing address

50855 WASHINGTON ST
LA QUINTA CA
92253-2891
US

V. Phone/Fax

Practice location:
  • Phone: 760-989-0384
  • Fax:
Mailing address:
  • Phone: 760-989-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210183984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: