Healthcare Provider Details

I. General information

NPI: 1982316436
Provider Name (Legal Business Name): MARINNA ASHLEE HARTWICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31946 MISSION TRL STE B
LAKE ELSINORE CA
92530-4539
US

IV. Provider business mailing address

28390 TODWELL AVE
ROMOLAND CA
92585-9195
US

V. Phone/Fax

Practice location:
  • Phone: 951-245-7663
  • Fax:
Mailing address:
  • Phone: 951-662-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number143368
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: