Provider Demographics
NPI:1588710453
Name:MAYO, AMY GERVASI (MFT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:GERVASI
Last Name:MAYO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4051
Mailing Address - Country:US
Mailing Address - Phone:650-438-7024
Mailing Address - Fax:650-359-3161
Practice Address - Street 1:205 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4051
Practice Address - Country:US
Practice Address - Phone:650-438-7024
Practice Address - Fax:650-359-3161
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40491171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA80641OtherMEDICAL