Healthcare Provider Details

I. General information

NPI: 1528134772
Provider Name (Legal Business Name): MARIANNE MICHELLE KABOUR PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 RYLAND ST
RENO NV
89502-1748
US

IV. Provider business mailing address

23516 NE 237TH ST
BATTLE GROUND WA
98604-5132
US

V. Phone/Fax

Practice location:
  • Phone: 775-982-5000
  • Fax:
Mailing address:
  • Phone: 650-793-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2566
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY1088
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: