Provider Demographics
NPI:1235482811
Name:MARMOLEJO, IRMA (SAC)
Entity Type:Individual
Prefix:MISS
First Name:IRMA
Middle Name:
Last Name:MARMOLEJO
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20226 E DAMERAL DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3939
Mailing Address - Country:US
Mailing Address - Phone:626-324-0390
Mailing Address - Fax:
Practice Address - Street 1:4340 WILSON ST
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3233
Practice Address - Country:US
Practice Address - Phone:909-590-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-107183101YA0400X
CAIMF88726106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)