=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396267845
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY TESORO M.A., LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3522 EL CAMINO REAL
-----------------------------------------------------
City | ATASCADERO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93422-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-226-6150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2859 SANTA BARBARA AVE
-----------------------------------------------------
City | CAYUCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93430-1549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-226-6150
-----------------------------------------------------
Fax | 805-226-6150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 99691
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------