Provider Demographics
NPI:1932536349
Name:VIRGIL, MARCINE L
Entity Type:Individual
Prefix:
First Name:MARCINE
Middle Name:L
Last Name:VIRGIL
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 1:47825 OASIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6950
Mailing Address - Country:US
Mailing Address - Phone:760-863-8505
Mailing Address - Fax:760-863-8587
Practice Address - Street 1:47825 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8505
Practice Address - Fax:760-863-8587
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAPT33912167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician