Provider Demographics
NPI:1073947685
Name:MARMOLEJO, MARSHALL J
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:J
Last Name:MARMOLEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18612 SANTA ANA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-2636
Mailing Address - Country:US
Mailing Address - Phone:909-421-7120
Mailing Address - Fax:909-421-7128
Practice Address - Street 1:18612 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-2636
Practice Address - Country:US
Practice Address - Phone:909-421-7120
Practice Address - Fax:909-421-7128
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)