Provider Demographics
NPI:1407581267
Name:QUELLMALZ, MARY LAWSON (AMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LAWSON
Last Name:QUELLMALZ
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25186 MANZANITA DR
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2632
Mailing Address - Country:US
Mailing Address - Phone:949-378-2200
Mailing Address - Fax:
Practice Address - Street 1:4540 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1815
Practice Address - Country:US
Practice Address - Phone:657-201-9192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist