Healthcare Provider Details

I. General information

NPI: 1124895099
Provider Name (Legal Business Name): MARINA DJORDJEVIC BT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARINA MCPHERSON

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CONCAR DR STE 4-134
SAN MATEO CA
94402-2681
US

IV. Provider business mailing address

400 CONCAR DR STE 4-134
SAN MATEO CA
94402-2681
US

V. Phone/Fax

Practice location:
  • Phone: 650-931-6300
  • Fax:
Mailing address:
  • Phone: 650-931-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: