Healthcare Provider Details

I. General information

NPI: 1053058909
Provider Name (Legal Business Name): MARISOL LATORRE DEWEESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

1522 E WASHINGTON ST
LONG BEACH CA
90805-6156
US

V. Phone/Fax

Practice location:
  • Phone: 213-842-2577
  • Fax:
Mailing address:
  • Phone: 714-616-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: