Healthcare Provider Details

I. General information

NPI: 1376989897
Provider Name (Legal Business Name): MARIE ROMAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 EMERALD ST
TORRANCE CA
90503-3105
US

IV. Provider business mailing address

446 11TH ST
HERMOSA BEACH CA
90254-4225
US

V. Phone/Fax

Practice location:
  • Phone: 310-371-4628
  • Fax:
Mailing address:
  • Phone: 310-902-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY18039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: