Provider Demographics
NPI:1346944857
Name:FOROUZAN, MARCIE MASON
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:MASON
Last Name:FOROUZAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARCIE
Other - Middle Name:LYNN
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4342 REDWOOD AVE # C214
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6480
Mailing Address - Country:US
Mailing Address - Phone:281-989-0725
Mailing Address - Fax:
Practice Address - Street 1:4342 REDWOOD AVE # C214
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6480
Practice Address - Country:US
Practice Address - Phone:281-989-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist