Healthcare Provider Details

I. General information

NPI: 1063954261
Provider Name (Legal Business Name): MARYANN VAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2016
Last Update Date: 11/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11306 HANNUM AVE
CULVER CITY CA
90230-6129
US

IV. Provider business mailing address

11306 HANNUM AVE
CULVER CITY CA
90230-6129
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-4850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW21566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: