Provider Demographics
NPI:1285764845
Name:MACAVORAY, MARY REDEMPTA
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:REDEMPTA
Last Name:MACAVORAY
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 1:1922 THE ALAMEDA STE 316
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1461
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-642-6052
Practice Address - Street 1:436 N WHITE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-1439
Practice Address - Country:US
Practice Address - Phone:408-269-0760
Practice Address - Fax:408-642-6052
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35027167G00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician