Active NPI
Mary M Fossum
- Marriage & Family Therapist
- Sacramento, CA
National Provider Identifier
1245582121
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Marriage & Family Therapist
- License
- MFC40137
- Practice address
- 1722 Professional Dr
Sacramento, CA 95825-2105 - Phone
- (916) 716-0095
- Fax
- (916) 973-9158
- NPI assigned
- Oct 3, 2012
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Marriage & Family Therapist | 106H00000X | MFC40137 | CA | Primary |
Addresses
Primary practice location
1722 Professional Dr
Sacramento, CA 95825-2105
Mailing address
1722 Professional Dr
Sacramento, CA 95825-2105
Phone (916) 716-0095
Other names 1
- Mrs. Elly M Fossum
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 25, 2024 through Jan 25, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MFC40137 | CA | MD | Marriage & Family Therapist |
| 40137 | CA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1349222400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1349222400000",
"number": "1245582121",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1722 PROFESSIONAL DR",
"city": "SACRAMENTO",
"state": "CA",
"postal_code": "958252105",
"telephone_number": "916-716-0095",
"fax_number": "916-973-9158"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1722 PROFESSIONAL DR",
"city": "SACRAMENTO",
"state": "CA",
"postal_code": "958252105",
"telephone_number": "916-716-0095",
"fax_number": "916-973-9158"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FOSSUM",
"first_name": "MARY",
"middle_name": "M",
"name_prefix": "Mrs.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2012-10-03",
"last_updated": "2012-10-03",
"status": "A"
},
"taxonomies": [
{
"code": "106H00000X",
"taxonomy_group": "",
"desc": "Marriage & Family Therapist",
"state": "CA",
"license": "MFC40137",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "ELLY",
"last_name": "FOSSUM",
"middle_name": "M",
"prefix": "MRS.",
"credential": "BA., MS",
"code": "2",
"type": "Professional Name"
}
]
}Other providers in Sacramento, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.