Provider Demographics
NPI:1194880880
Name:BRYAN, MARY KATHLEEN (MFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 GRAYLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2221
Mailing Address - Country:US
Mailing Address - Phone:707-769-9648
Mailing Address - Fax:707-769-9648
Practice Address - Street 1:1330 LINCOLN AVE STE 303
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2143
Practice Address - Country:US
Practice Address - Phone:415-455-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT#21232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health