Healthcare Provider Details

I. General information

NPI: 1265773543
Provider Name (Legal Business Name): MRS. MARY LOU BITTNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 TEXAS ST STE 203
SAN DIEGO CA
92108-3723
US

IV. Provider business mailing address

5005 TEXAS ST STE 203
SAN DIEGO CA
92108-3723
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-0727
  • Fax:
Mailing address:
  • Phone: 619-692-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: