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General NPI Number Information
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NPI Number | 1538868377
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Entity Type | Individual
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Provider Name | MARY MARIE MCRAE
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Gender | Female
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Dates
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Enumeration Date | 03/01/2023
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Last Update Date | 12/05/2023
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Provider Practice Location Address
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Address Line | 5005 CANYON CREST DR
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City | RIVERSIDE
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State | CA
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Zip | 92507-7721
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Country | US
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Telephone | 323-825-9182
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Fax |
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Provider Business Mailing Address
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Address Line | 2028 SHADETREE LN
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City | ESCONDIDO
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State | CA
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Zip | 92029-5303
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Country | US
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Telephone | 760-835-9681
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Fax |
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 94028048
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License Number State | CA
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