Provider Demographics
NPI:1275659393
Name:DECILLIS, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:DECILLIS
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 1:5468 THUNDER RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4854
Mailing Address - Country:US
Mailing Address - Phone:916-624-5410
Mailing Address - Fax:
Practice Address - Street 1:2351 SUNSET BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4338
Practice Address - Country:US
Practice Address - Phone:916-624-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist