Provider Demographics
NPI:1366081895
Name:FRYMAN, MARSHALL BUCKLEY (MA)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:BUCKLEY
Last Name:FRYMAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15217 SAN BERNARDINO AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5327
Mailing Address - Country:US
Mailing Address - Phone:951-643-2150
Mailing Address - Fax:
Practice Address - Street 1:15217 SAN BERNARDINO AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5327
Practice Address - Country:US
Practice Address - Phone:951-643-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-01
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA17226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program