Provider Demographics
NPI:1144925926
Name:CORTEZ, MARY CARMEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CARMEN
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BROADWAY STE 207
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2767
Mailing Address - Country:US
Mailing Address - Phone:619-425-5609
Mailing Address - Fax:619-425-8349
Practice Address - Street 1:23121 VERDUGO DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1339
Practice Address - Country:US
Practice Address - Phone:949-520-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAAMFT146221106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program