Healthcare Provider Details

I. General information

NPI: 1215477609
Provider Name (Legal Business Name): MARY O'HERN MATULICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY O'HERN

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W BROADWAY STE 400
SAN DIEGO CA
92101-3554
US

IV. Provider business mailing address

402 W BROADWAY STE 400
SAN DIEGO CA
92101-3554
US

V. Phone/Fax

Practice location:
  • Phone: 866-478-3978
  • Fax:
Mailing address:
  • Phone: 866-478-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT121866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: