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General NPI Number Information
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NPI Number | 1942433651
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Entity Type | Individual
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Provider Name | MARINA ALEXANDRIA BIALLO-DERY PHD
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Gender | Female
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/27/2009
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Provider Practice Location Address
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Address Line | 28521 PASEO DIANA
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City | SAN JUAN CAPISTRANO
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State | CA
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Zip | 92675-2905
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Country | US
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Telephone | 949-616-2918
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Fax |
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Provider Business Mailing Address
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Address Line | 4199 CAMPUS DR STE 550
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City | IRVINE
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State | CA
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Zip | 92612-4694
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Country | US
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Telephone | 949-616-2918
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT 30304
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License Number State | CA
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