Healthcare Provider Details

I. General information

NPI: 1669789384
Provider Name (Legal Business Name): MARISOL PEREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 TOWN CENTER DR
MONTEBELLO CA
90640-2173
US

IV. Provider business mailing address

1550 TOWN CENTER DR
MONTEBELLO CA
90640-2173
US

V. Phone/Fax

Practice location:
  • Phone: 323-724-7166
  • Fax:
Mailing address:
  • Phone: 323-724-7166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number31066
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW72279
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: