Provider Demographics
NPI:1487152161
Name:FAVORS, MARLENE
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:FAVORS
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 1:7439 LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2655
Mailing Address - Country:US
Mailing Address - Phone:714-791-4161
Mailing Address - Fax:
Practice Address - Street 1:7281 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4212
Practice Address - Country:US
Practice Address - Phone:714-791-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT99581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty