Healthcare Provider Details

I. General information

NPI: 1851598809
Provider Name (Legal Business Name): MARILYN DENISE DYSON IMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9728 S 5TH AVE
INGLEWOOD CA
90305-3204
US

IV. Provider business mailing address

PO BOX 45193
LOS ANGELES CA
90045-0191
US

V. Phone/Fax

Practice location:
  • Phone: 310-350-3832
  • Fax:
Mailing address:
  • Phone: 310-350-3832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 46490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: