Provider Demographics
NPI:1417111709
Name:IMMOOS, MARILYN SUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:SUE
Last Name:IMMOOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARILYN
Other - Middle Name:SUE
Other - Last Name:IMMOOS-LANGLOIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:323 EDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640-5204
Mailing Address - Country:US
Mailing Address - Phone:209-274-2362
Mailing Address - Fax:
Practice Address - Street 1:323 EDGEBROOK DR
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640-5204
Practice Address - Country:US
Practice Address - Phone:209-274-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical