Provider Demographics
NPI:1730400862
Name:TUDOR BLEAK, MARILYN L (MFT)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:L
Last Name:TUDOR BLEAK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:L
Other - Last Name:TUDOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 18325
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-9998
Mailing Address - Country:US
Mailing Address - Phone:949-300-5228
Mailing Address - Fax:949-833-1797
Practice Address - Street 1:2900 BRISTOL STREET
Practice Address - Street 2:SUITE J101
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:949-300-5228
Practice Address - Fax:949-833-1797
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46562106H00000X
CAMFC4656Z106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist