MEDICARE: DR. TINA MARIE MARIN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY 20292	CA

General Provider Information

NPI Number	:	1275736704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TINA MARIE MARIN PH.D.

Provider Business Mailing Address
First Line	:	46141 MIRAMAR WAY
Second Line	:	SUITE 1
City	:	SAN DIEGO
State	:	CA
Zip	:	92145-5401
Country	:	US
Telephone Number	:	858-577-7048
Fax Number	:	858-577-7154

Provider Business Practice Location Address
First Line	:	46141 MIRAMAR WAY
Second Line	:	SUITE 1
City	:	SAN DIEGO
State	:	CA
Zip	:	92145-5401
Country	:	US
Telephone Number	:	858-577-7048
Fax Number	:	858-577-7154

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	07/08/2007

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