Provider Demographics
NPI:1083253751
Name:GLICK, MARNI
Entity Type:Individual
Prefix:
First Name:MARNI
Middle Name:
Last Name:GLICK
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 1:11712 MOORPARK ST STE 211
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2164
Mailing Address - Country:US
Mailing Address - Phone:818-875-0124
Mailing Address - Fax:
Practice Address - Street 1:11712 MOORPARK ST STE 211
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2164
Practice Address - Country:US
Practice Address - Phone:818-875-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117104106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist