Provider Demographics
NPI:1881291193
Name:GRIJALVA, MARLENE (LMFT)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:GRIJALVA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15051 SONNY CIR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-2913
Mailing Address - Country:US
Mailing Address - Phone:949-246-8723
Mailing Address - Fax:
Practice Address - Street 1:250 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3655
Practice Address - Country:US
Practice Address - Phone:949-246-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119144106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist