MEDICARE: MARLENE DAREY URBAITIS PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY13310	CA

General Provider Information

NPI Number	:	1912181165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLENE DAREY URBAITIS PHD

Provider Business Mailing Address
First Line	:	11633 SAN VICENTE BLVD STE 320
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-6514
Country	:	US
Telephone Number	:	310-392-2939
Fax Number	:

Provider Business Practice Location Address
First Line	:	11633 SAN VICENTE BLVD STE 320
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-6514
Country	:	US
Telephone Number	:	310-392-2939
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	12/24/2007

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