MEDICARE: DR. MARY SPEASE PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY24780	CA
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	PSY24780	CA
3	103TC0700X	Clinical Psychologist	PSY24780	CA
4	103TC1900X	Counseling Psychologist	PSY24780	CA

General Provider Information

NPI Number	:	1780879809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY SPEASE PSY.D.

Provider Business Mailing Address
First Line	:	5405 MOREHOUSE DR
Second Line	:	SUITE 330
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-4722
Country	:	US
Telephone Number	:	858-888-3261
Fax Number	:

Provider Business Practice Location Address
First Line	:	5405 MOREHOUSE DR
Second Line	:	SUITE 330
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-4722
Country	:	US
Telephone Number	:	858-888-3261
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2007
Last Update Date	:	02/16/2016

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