Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003068966 |
---|---|
Provider Name | Mary Lightholder |
First Address | Fremont, CA 94539-4501 |
Second Address | San Leandro, CA 94577-2757 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/10/2008 |
Last Update Date | 30/08/2012 |