Healthcare Provider Details

I. General information

NPI: 1780332361
Provider Name (Legal Business Name): MR. MICHAEL GIFFORD MARZONI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 JUTLAND DR STE 207
SAN DIEGO CA
92117-3653
US

IV. Provider business mailing address

4241 JUTLAND DR STE 207
SAN DIEGO CA
92117-3653
US

V. Phone/Fax

Practice location:
  • Phone: 619-733-6414
  • Fax: 619-303-3306
Mailing address:
  • Phone: 619-733-6414
  • Fax: 619-303-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number156120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: