Provider Demographics
NPI:1164655031
Name:MARSHALL, LA REINA P
Entity Type:Individual
Prefix:
First Name:LA REINA
Middle Name:P
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LA REINA
Other - Middle Name:P
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:54 KNOLLS LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8318
Mailing Address - Country:US
Mailing Address - Phone:707-342-2025
Mailing Address - Fax:
Practice Address - Street 1:634 PRESSLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5526
Practice Address - Country:US
Practice Address - Phone:707-573-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6789OtherMEDI CAL