Provider Demographics
NPI:1609908417
Name:MALLY, MARIKO (MFT, RN)
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:
Last Name:MALLY
Suffix:
Gender:F
Credentials:MFT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 MELODY LN
Mailing Address - Street 2:SUITE 122
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5193
Mailing Address - Country:US
Mailing Address - Phone:916-715-9894
Mailing Address - Fax:866-910-7576
Practice Address - Street 1:1110 MELODY LN
Practice Address - Street 2:SUITE 122
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5193
Practice Address - Country:US
Practice Address - Phone:916-715-9894
Practice Address - Fax:866-910-7576
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37252106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9998Medicaid