Basic Information
| Provider Information | |||||||||
| NPI: | 1992752091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENCIL | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 609001 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 621909001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195284600 | ||||||||
| FaxNumber: | 6195284625 | ||||||||
| Practice Location | |||||||||
| Address1: | 5353 MISSION CENTER RD | ||||||||
| Address2: | SUITE 224 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921081304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196885855 | ||||||||
| FaxNumber: | 6192913310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY16217 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.