Provider Demographics
NPI:1497156517
Name:MARVIN, AUDRA MEGAN (MFTI # 73521)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:MEGAN
Last Name:MARVIN
Suffix:
Gender:F
Credentials:MFTI # 73521
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 N MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3610
Mailing Address - Country:US
Mailing Address - Phone:619-697-7477
Mailing Address - Fax:
Practice Address - Street 1:460 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3610
Practice Address - Country:US
Practice Address - Phone:619-697-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI #73521106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist