Healthcare Provider Details

I. General information

NPI: 1649348632
Provider Name (Legal Business Name): MARISSA ALINA PEREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 LONG BEACH BLVD
LONG BEACH CA
90806-5501
US

IV. Provider business mailing address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 562-599-6476
  • Fax:
Mailing address:
  • Phone: 323-346-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number27579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: