Healthcare Provider Details

I. General information

NPI: 1124253588
Provider Name (Legal Business Name): LIZA V MARAVILLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 QUEBEC AVENUE
CORCORAN CA
93212
US

IV. Provider business mailing address

900 QUEBEC AVENUE
CORCORAN CA
93212
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-7100
  • Fax: 559-992-7104
Mailing address:
  • Phone: 559-992-7100
  • Fax: 559-992-7104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS25244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: