Provider Demographics
NPI:1861529794
Name:VANDERMOER, MARYLYN O (MFT)
Entity type:Individual
Prefix:MRS
First Name:MARYLYN
Middle Name:O
Last Name:VANDERMOER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7936 LAKE ADLON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3117
Mailing Address - Country:US
Mailing Address - Phone:619-563-2743
Mailing Address - Fax:
Practice Address - Street 1:3255 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3806
Practice Address - Country:US
Practice Address - Phone:619-563-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC24691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist