Provider Demographics
NPI:1427088699
Name:FOX, MARILLA L (PHD)
Entity type:Individual
Prefix:
First Name:MARILLA
Middle Name:L
Last Name:FOX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-7042
Mailing Address - Country:US
Mailing Address - Phone:515-232-5811
Mailing Address - Fax:515-232-7491
Practice Address - Street 1:125 S 3RD ST
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-7042
Practice Address - Country:US
Practice Address - Phone:515-232-5811
Practice Address - Fax:515-232-7491
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00824103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS48272Medicare UPIN
IA42168Medicare ID - Type Unspecified