Healthcare Provider Details

I. General information

NPI: 1972039071
Provider Name (Legal Business Name): MARISA HUGHES LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 N HARBOR BLVD SUITE C
FULLERTON CA
92835-1362
US

IV. Provider business mailing address

5545 WOODRUFF AVE #35
LAKEWOOD CA
90713-1534
US

V. Phone/Fax

Practice location:
  • Phone: 657-464-5188
  • Fax:
Mailing address:
  • Phone: 657-464-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: