=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255040770
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY PAT LEONIE PAULSON APCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2022
-----------------------------------------------------
Last Update Date | 11/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 BROADBECK DR
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-242-3120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2580 YUCCA DR
-----------------------------------------------------
City | SANTA ROSA VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-9377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-519-1795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 11226
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------