Provider Demographics
NPI:1649478488
Name:NEWCOMER, MARY GROVER
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GROVER
Last Name:NEWCOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MEG
Other - Middle Name:G
Other - Last Name:NEWCOMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:241 RICHARDSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2518
Mailing Address - Country:US
Mailing Address - Phone:415-377-9361
Mailing Address - Fax:
Practice Address - Street 1:205 CAMINO ALTO
Practice Address - Street 2:STE 270
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-457-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12391103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL123910OtherBLUE SHIELD