Provider Demographics
NPI:1588837132
Name:LEWIS, MARILYN KAY (MFT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:KAY
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4565 RUFFNER ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2258
Mailing Address - Country:US
Mailing Address - Phone:858-492-9985
Mailing Address - Fax:858-277-1951
Practice Address - Street 1:4565 RUFFNER ST STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2258
Practice Address - Country:US
Practice Address - Phone:858-492-9985
Practice Address - Fax:858-277-1951
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40220106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist