Provider Demographics
NPI:1699876540
Name:FRIESEN, MARILYN RUTH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:RUTH
Last Name:FRIESEN
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 1:4323 N ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1222
Mailing Address - Country:US
Mailing Address - Phone:619-641-7090
Mailing Address - Fax:619-463-2463
Practice Address - Street 1:3111 CAMINO DEL RIO N
Practice Address - Street 2:STE 400
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5720
Practice Address - Country:US
Practice Address - Phone:619-641-7090
Practice Address - Fax:619-463-2463
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8986103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPMOO8986Medicaid
CAMFCP8986Medicare ID - Type Unspecified