Provider Demographics
NPI:1972193944
Name:EGERTSON, MARIE J
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:J
Last Name:EGERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 WILLIAMS DR STE 101
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-2613
Mailing Address - Country:US
Mailing Address - Phone:805-981-4200
Mailing Address - Fax:
Practice Address - Street 1:1756 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-383-3669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143584106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA941735271Other1831308659
CA941735271Other1578772323
CA941735271Other1518176379
CA941735271Other1982813721