Provider Demographics
NPI:1538868377
Name:MCRAE, MARY MARIE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARIE
Last Name:MCRAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARS
Other - Middle Name:M
Other - Last Name:MCRAE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2028 SHADETREE LN
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-5303
Mailing Address - Country:US
Mailing Address - Phone:760-835-9681
Mailing Address - Fax:
Practice Address - Street 1:5005 CANYON CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7721
Practice Address - Country:US
Practice Address - Phone:323-825-9182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA94028048390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health