Provider Demographics
NPI:1316954712
Name:ISHII, MARY I (PSYD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:I
Last Name:ISHII
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:BOX 016960 (M851)
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-1428
Mailing Address - Fax:
Practice Address - Street 1:1800 NW 10TH AVE
Practice Address - Street 2:RYDER TRAUMA CENTER - T331
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1018
Practice Address - Country:US
Practice Address - Phone:305-585-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5879103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS95361Medicare UPIN