Provider Demographics
NPI:1942433651
Name:BIALLO-DERY, MARINA ALEXANDRIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:ALEXANDRIA
Last Name:BIALLO-DERY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4199 CAMPUS DR STE 550
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-4694
Mailing Address - Country:US
Mailing Address - Phone:949-616-2918
Mailing Address - Fax:
Practice Address - Street 1:28521 PASEO DIANA
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2905
Practice Address - Country:US
Practice Address - Phone:949-616-2918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 30304106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist