Provider Demographics
NPI:1053628388
Name:PASSEHL, MARY KATHLEEN (MFT, PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:PASSEHL
Suffix:
Gender:F
Credentials:MFT, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24637 GARDENSTONE LN
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-3815
Mailing Address - Country:US
Mailing Address - Phone:805-427-3718
Mailing Address - Fax:
Practice Address - Street 1:11965 VENICE BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3979
Practice Address - Country:US
Practice Address - Phone:310-566-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35693106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist