Provider Demographics
NPI:1619565496
Name:SKOURAS, MARIELLE (MA, AMFT)
Entity Type:Individual
Prefix:MS
First Name:MARIELLE
Middle Name:
Last Name:SKOURAS
Suffix:
Gender:F
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12348-B VENTURA BLVD.
Mailing Address - Street 2:#152
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604
Mailing Address - Country:US
Mailing Address - Phone:424-256-3969
Mailing Address - Fax:
Practice Address - Street 1:12348-B VENTURA BLVD.
Practice Address - Street 2:#152
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604
Practice Address - Country:US
Practice Address - Phone:424-256-3969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117604106H00000X
CALMFT126451106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA126451OtherBOARD OF BEHAVIORAL SCIENCES