Provider Demographics
NPI:1164853701
Name:DICK, MARNI JEAN (BCBA)
Entity Type:Individual
Prefix:MS
First Name:MARNI
Middle Name:JEAN
Last Name:DICK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20569 PONDEROSA WAY
Mailing Address - Street 2:
Mailing Address - City:TUOLUMNE
Mailing Address - State:CA
Mailing Address - Zip Code:95379-8700
Mailing Address - Country:US
Mailing Address - Phone:209-535-0950
Mailing Address - Fax:
Practice Address - Street 1:20569 PONDEROSA WAY
Practice Address - Street 2:
Practice Address - City:TUOLUMNE
Practice Address - State:CA
Practice Address - Zip Code:95379-8700
Practice Address - Country:US
Practice Address - Phone:209-535-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-07-3211103K00000X
CA1-19-37875103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst