Healthcare Provider Details

I. General information

NPI: 1821370941
Provider Name (Legal Business Name): MARIAN E DALE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 CHRISTINE CT
SAN PABLO CA
94806-1201
US

IV. Provider business mailing address

95 CHRISTINE CT
SAN PABLO CA
94806-1201
US

V. Phone/Fax

Practice location:
  • Phone: 510-222-5738
  • Fax: 510-223-0838
Mailing address:
  • Phone: 510-222-5738
  • Fax: 510-223-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number18257
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number18257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: