Provider Demographics
NPI:1134337066
Name:COBURN, MARJORIE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:
Last Name:COBURN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 PROSPECT ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4213
Mailing Address - Country:US
Mailing Address - Phone:858-456-5065
Mailing Address - Fax:
Practice Address - Street 1:836 PROSPECT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4213
Practice Address - Country:US
Practice Address - Phone:858-456-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8758103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP8758Medicare ID - Type Unspecified