=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073552899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLYNE DIANE ROBERTS L.M.F.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 RIMPAU AVE
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-5724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-924-3494
-----------------------------------------------------
Fax | 951-488-1156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 52573
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92517-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-924-3494
-----------------------------------------------------
Fax | 951-488-1156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------