Provider Demographics
NPI:1912119876
Name:DOUSETTE, MARY THERESA (PHD MFT)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:THERESA
Last Name:DOUSETTE
Suffix:
Gender:F
Credentials:PHD MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 AUCKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602
Mailing Address - Country:US
Mailing Address - Phone:818-980-0202
Mailing Address - Fax:818-952-8635
Practice Address - Street 1:4507 AUCKLAND AVE
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602
Practice Address - Country:US
Practice Address - Phone:818-980-0202
Practice Address - Fax:818-952-8635
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18158103TC0700X
CAMK22157106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist