Healthcare Provider Details

I. General information

NPI: 1144148057
Provider Name (Legal Business Name): MARINA DUTROW PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6537 W 2ND ST
RIO LINDA CA
95673-3231
US

IV. Provider business mailing address

5115 DUDLEY BLVD
MCCLELLAN CA
95652-1024
US

V. Phone/Fax

Practice location:
  • Phone: 916-566-1990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: