Provider Demographics
NPI:1902151939
Name:FURUBOTTEN, MARILYN DIANE
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:DIANE
Last Name:FURUBOTTEN
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 1:7120 FRANKLIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046
Mailing Address - Country:US
Mailing Address - Phone:323-876-0550
Mailing Address - Fax:323-436-7041
Practice Address - Street 1:7120 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-3002
Practice Address - Country:US
Practice Address - Phone:323-876-0550
Practice Address - Fax:323-436-7041
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist