Healthcare Provider Details

I. General information

NPI: 1053647453
Provider Name (Legal Business Name): MARISOL ELIZARRARAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 F ST
CHULA VISTA CA
91910-3711
US

IV. Provider business mailing address

430 F ST
CHULA VISTA CA
91910-3711
US

V. Phone/Fax

Practice location:
  • Phone: 619-420-3620
  • Fax:
Mailing address:
  • Phone: 619-420-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: