Provider Demographics
NPI:1972660843
Name:SQUIRE, MARY D (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:SQUIRE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 OAK ALLEY CT
Mailing Address - Street 2:SUITE 305
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1306
Mailing Address - Country:US
Mailing Address - Phone:419-534-2468
Mailing Address - Fax:419-534-2397
Practice Address - Street 1:3454 OAK ALLEY CT
Practice Address - Street 2:SUITE 305
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1306
Practice Address - Country:US
Practice Address - Phone:419-534-2468
Practice Address - Fax:419-534-2397
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4955103T00000X
MI6301010437103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist