Provider Demographics
NPI:1295208908
Name:MARMOLEJO, RUDY
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:
Last Name:MARMOLEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 N LAKE AVE # 150
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2301
Mailing Address - Country:US
Mailing Address - Phone:626-794-1161
Mailing Address - Fax:
Practice Address - Street 1:1450 N LAKE AVE # 150
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2301
Practice Address - Country:US
Practice Address - Phone:626-794-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)