Provider Demographics
NPI:1821490855
Name:KING, MARIAM JANE (PSY,D)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:JANE
Last Name:KING
Suffix:
Gender:F
Credentials:PSY,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 CAMINO ALTO
Mailing Address - Street 2:SUITE E1
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2254
Mailing Address - Country:US
Mailing Address - Phone:510-307-4356
Mailing Address - Fax:
Practice Address - Street 1:131 CAMINO ALTO
Practice Address - Street 2:SUITE E1
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2254
Practice Address - Country:US
Practice Address - Phone:510-307-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22983103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist