Healthcare Provider Details

I. General information

NPI: 1477839850
Provider Name (Legal Business Name): MS. MARIE MICHELLE MERCADO REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45111 FERN AVE
LANCASTER CA
93534-2301
US

IV. Provider business mailing address

654 N MADISON AVE
PASADENA CA
91101-1110
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-1206
  • Fax: 661-940-5452
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number56078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: