Provider Demographics
NPI:1245551761
Name:AMPUERO, MARILYN C (MA,MED,LPCC,LMFT)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:C
Last Name:AMPUERO
Suffix:
Gender:F
Credentials:MA,MED,LPCC,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 S BASCOM AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3535
Mailing Address - Country:US
Mailing Address - Phone:408-410-6217
Mailing Address - Fax:
Practice Address - Street 1:1210 S BASCOM AVE STE 114
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3535
Practice Address - Country:US
Practice Address - Phone:408-410-6217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA621101YM0800X
CA84760106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health