Provider Demographics
NPI:1912210022
Name:MAUTNER, PEARLY KIT-MAN
Entity type:Individual
Prefix:
First Name:PEARLY
Middle Name:KIT-MAN
Last Name:MAUTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PEARLY
Other - Middle Name:KIT-MAN
Other - Last Name:YEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 LINCOLN CT
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9353 VALLEY BLVD STE C
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-1934
Practice Address - Country:US
Practice Address - Phone:626-287-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-17
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA32466101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor