Provider Demographics
NPI:1912059973
Name:MARSOLAIS, MIRIAM
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:
Last Name:MARSOLAIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 VINCENTE AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1521
Mailing Address - Country:US
Mailing Address - Phone:510-525-0244
Mailing Address - Fax:
Practice Address - Street 1:376 COLUSA AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94707-1213
Practice Address - Country:US
Practice Address - Phone:510-525-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18619103TA0700X, 103TC0700X, 103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01474304OtherMEDICAL ALAMEDA COUNTY
CAOPL186190Medicare ID - Type Unspecified