Healthcare Provider Details

I. General information

NPI: 1831489681
Provider Name (Legal Business Name): MARYVALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E HUNTINGTON DR
DUARTE CA
91010
US

IV. Provider business mailing address

2502 E HUNTINGTON DR
DUARTE CA
91010-2221
US

V. Phone/Fax

Practice location:
  • Phone: 626-357-1514
  • Fax: 626-359-4285
Mailing address:
  • Phone: 626-357-1514
  • Fax: 626-359-4285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE LYNN CULVER
Title or Position: SENIOR DIRECTOR OF COMMUNITY BASED
Credential:
Phone: 626-263-9133