Provider Demographics
NPI:1225155500
Name:MILLARD, MARIE MAYNARD (MFT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:MAYNARD
Last Name:MILLARD
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 1:2900 4TH AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5918
Mailing Address - Country:US
Mailing Address - Phone:619-295-1214
Mailing Address - Fax:619-295-1214
Practice Address - Street 1:2900 4TH AVE
Practice Address - Street 2:STE. 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5918
Practice Address - Country:US
Practice Address - Phone:619-295-1214
Practice Address - Fax:619-295-1214
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 36619106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist