Provider Demographics
NPI:1255434999
Name:EDELBROCK, MARIAN R C (PHD)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:R C
Last Name:EDELBROCK
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 1:13794 ROSECROFT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-5106
Mailing Address - Country:US
Mailing Address - Phone:619-948-9393
Mailing Address - Fax:
Practice Address - Street 1:6370 LUSK BLVD
Practice Address - Street 2:F103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2753
Practice Address - Country:US
Practice Address - Phone:619-948-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15260103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY152600Medicaid
CAPSY152600Medicaid