Provider Demographics
NPI:1225297195
Name:ENTEZAR, MARY M
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:ENTEZAR
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 1:921 TRIBUNE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3422
Mailing Address - Country:US
Mailing Address - Phone:909-809-9293
Mailing Address - Fax:
Practice Address - Street 1:921 TRIBUNE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3422
Practice Address - Country:US
Practice Address - Phone:909-809-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156823106H00000X, 106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist