Provider Demographics
NPI:1083185029
Name:VICE, MARYLYNN (LMFT)
Entity type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:
Last Name:VICE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 MURRIETA BLVD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4111
Mailing Address - Country:US
Mailing Address - Phone:925-337-1805
Mailing Address - Fax:
Practice Address - Street 1:1062 MURRIETA BLVD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4111
Practice Address - Country:US
Practice Address - Phone:925-337-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA110258106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty