Provider Demographics
NPI:1851598809
Name:DYSON, MARILYN DENISE (IMFT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:DENISE
Last Name:DYSON
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45193
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-0191
Mailing Address - Country:US
Mailing Address - Phone:310-350-3832
Mailing Address - Fax:
Practice Address - Street 1:9728 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-3204
Practice Address - Country:US
Practice Address - Phone:310-350-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 46490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist