Basic Information
| Provider Information | |||||||||
| NPI: | 1679744577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURAU | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURAU | ||||||||
| OtherFirstName: | MARIE | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1911 WILLIAMS DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930362665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059814200 | ||||||||
| FaxNumber: | 8059813341 | ||||||||
| Practice Location | |||||||||
| Address1: | 1911 WILLIAMS DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930362665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059814200 | ||||||||
| FaxNumber: | 8059813341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 45378 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.