Provider Demographics
NPI:1730814617
Name:PALUMBO, MARIE ANTOINETTE (LMFT)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:PALUMBO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 BELLO ST
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2121
Practice Address - Country:US
Practice Address - Phone:805-704-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-23
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT39803106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist