Provider Demographics
NPI:1225130693
Name:WATSON, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:WATSON
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 1:2800 HOFFMAN BLUFF WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4522
Mailing Address - Country:US
Mailing Address - Phone:916-488-1967
Mailing Address - Fax:
Practice Address - Street 1:2800 HOFFMAN BLUFF WAY
Practice Address - Street 2:6147 SUTTER AVE
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4522
Practice Address - Country:US
Practice Address - Phone:916-488-1967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19223106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1569OtherMEDI-CAL ID NUMBER