1760645998 NPI number — ANKHESENAMUN BALL MARIONI PSY.D

Table of content: ANKHESENAMUN BALL MARIONI PSY.D (NPI 1760645998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760645998 NPI number — ANKHESENAMUN BALL MARIONI PSY.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARIONI
Provider First Name:
ANKHESENAMUN
Provider Middle Name:
BALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALL
Provider Other First Name:
ANKHESENAMUN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1760645998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1918 BONITA AVE # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94704-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-269-7607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 GRAND AVE STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94610-3548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-269-7607
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 24781 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)