Provider Demographics
NPI:1215477609
Name:MATULICH, MARY O'HERN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:O'HERN
Last Name:MATULICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:O'HERN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:402 W BROADWAY STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3554
Mailing Address - Country:US
Mailing Address - Phone:866-478-3978
Mailing Address - Fax:
Practice Address - Street 1:402 W BROADWAY STE 400
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3554
Practice Address - Country:US
Practice Address - Phone:866-478-3978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT121866106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist