Healthcare Provider Details

I. General information

NPI: 1134466204
Provider Name (Legal Business Name): MARY E COOMBS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3763 HATCHERS CIR
STOCKTON CA
95219-3106
US

IV. Provider business mailing address

PO BOX 4704
STOCKTON CA
95204-0704
US

V. Phone/Fax

Practice location:
  • Phone: 209-655-4825
  • Fax:
Mailing address:
  • Phone: 801-550-8075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9781431-3502
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW111069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: