Provider Demographics
NPI:1508987090
Name:DAVIS, MARILYN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 DOVE ST STE 260
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2803
Mailing Address - Country:US
Mailing Address - Phone:949-476-7033
Mailing Address - Fax:949-476-7035
Practice Address - Street 1:1101 DOVE ST STE 260
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2803
Practice Address - Country:US
Practice Address - Phone:949-476-7033
Practice Address - Fax:949-476-7035
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 7685103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
33-0380914OtherFEDERAL TAX ID NUMBER