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General NPI Number Information
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NPI Number | 1194880880
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Entity Type | Individual
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Provider Name | MARY KATHLEEN BRYAN MFT
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Gender | Female
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Dates
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Enumeration Date | 12/24/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1330 LINCOLN AVE STE 303
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City | SAN RAFAEL
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State | CA
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Zip | 94901-2143
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Country | US
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Telephone | 415-455-4771
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Fax |
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Provider Business Mailing Address
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Address Line | 42 GRAYLAWN AVE
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City | PETALUMA
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State | CA
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Zip | 94952-2221
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Country | US
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Telephone | 707-769-9648
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Fax | 707-769-9648
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MFT#21232
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License Number State | CA
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