Healthcare Provider Details

I. General information

NPI: 1184134348
Provider Name (Legal Business Name): MARINA KAMINETSKAYA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 MAIDU DR
AUBURN CA
95603-5808
US

IV. Provider business mailing address

PO BOX 513
ROCKLIN CA
95677-0513
US

V. Phone/Fax

Practice location:
  • Phone: 530-888-1118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number29179
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number29179
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: