Provider Demographics
NPI:1992262521
Name:MOUNTAIN, MARILYN T (LMFT)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:T
Last Name:MOUNTAIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:MOUNTAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:203 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2125
Mailing Address - Country:US
Mailing Address - Phone:949-752-9708
Mailing Address - Fax:
Practice Address - Street 1:1601 DOVE ST STE 230
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1423
Practice Address - Country:US
Practice Address - Phone:949-752-9708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT34583106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT34583OtherBBS