=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548724545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA WILEATHA GLIVINGS PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 01/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41990 COOK ST BLDG F
-----------------------------------------------------
City | PALM DESERT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92211-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-341-5570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2443 FAIR OAKS BLVD # 117
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-7684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 29967
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------