Provider Demographics
NPI:1487306726
Name:MARIN, MALLORY KAI
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAI
Last Name:MARIN
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 1:4212 VICTORINE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-1848
Mailing Address - Country:US
Mailing Address - Phone:323-610-5110
Mailing Address - Fax:
Practice Address - Street 1:2165 D ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5422
Practice Address - Country:US
Practice Address - Phone:323-610-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty