Provider Demographics
NPI:1003977737
Name:SYVERSON, MARILYN OLENA
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:OLENA
Last Name:SYVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0441
Mailing Address - Country:US
Mailing Address - Phone:541-207-8606
Mailing Address - Fax:
Practice Address - Street 1:891 NW GRANT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4539
Practice Address - Country:US
Practice Address - Phone:541-207-8606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1905101YM0800X
TX8708101YM0800X
WALH00010330101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health