Healthcare Provider Details

I. General information

NPI: 1255045894
Provider Name (Legal Business Name): MARISA DAGENHART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 03/23/2025
Certification Date: 03/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 7524
MORENO VALLEY CA
92552-7524
US

IV. Provider business mailing address

PO BOX 7524
MORENO VALLEY CA
92552-7524
US

V. Phone/Fax

Practice location:
  • Phone: 951-956-9229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: