Healthcare Provider Details

I. General information

NPI: 1295585735
Provider Name (Legal Business Name): MARISA ANN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 RIVERVIEW DR
JURUPA VALLEY CA
92509-6611
US

IV. Provider business mailing address

4041 TANO ST
CHINO CA
91710-4854
US

V. Phone/Fax

Practice location:
  • Phone: 951-360-4175
  • Fax:
Mailing address:
  • Phone: 951-212-1749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number123042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: