Provider Demographics
NPI:1487817292
Name:CORDAHL, MARYANNE NONE (PHD)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:NONE
Last Name:CORDAHL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9404 GENESEE AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-717-4200
Mailing Address - Fax:
Practice Address - Street 1:9404 GENESEE AVE
Practice Address - Street 2:SUITE 335
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-717-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21025103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21025OtherLICENSED CLINICAL PSYCHOLOGIST
CA51664OtherNATIONAL REGISTER OF HEALTH SERVICE PROVIDERS IN PSYCHOLOGY