Provider Demographics
NPI:1215017124
Name:SERVEDIO, MARCIA S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:S
Last Name:SERVEDIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3323
Mailing Address - Country:US
Mailing Address - Phone:626-842-8412
Mailing Address - Fax:
Practice Address - Street 1:250 W STATE ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3323
Practice Address - Country:US
Practice Address - Phone:626-842-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13865103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP13865DMedicare ID - Type UnspecifiedPROVIDER NO.
CAOPL138650Medicare ID - Type UnspecifiedPROVIDER NO.