Provider Demographics
NPI:1225297195
Name:ENTEZAR, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ENTEZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4926
Mailing Address - Country:US
Mailing Address - Phone:951-654-6002
Mailing Address - Fax:
Practice Address - Street 1:790 S STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4924
Practice Address - Country:US
Practice Address - Phone:951-654-6002
Practice Address - Fax:951-658-7140
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130593106H00000X, 101YP2500X
91016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional