Provider Demographics
NPI:1225073919
Name:GOTTDANK, MARILYN (MFT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:GOTTDANK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N EL CAMINO REAL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4789
Mailing Address - Country:US
Mailing Address - Phone:949-366-4191
Mailing Address - Fax:949-366-4107
Practice Address - Street 1:501 N EL CAMINO REAL
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4789
Practice Address - Country:US
Practice Address - Phone:949-366-4191
Practice Address - Fax:949-366-4107
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17338106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist