Healthcare Provider Details

I. General information

NPI: 1013095629
Provider Name (Legal Business Name): MARYLOUISE NONE BARROS-NISKA MFCC AND PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SILVER SPUR RD STE 101
ROLLING HILLS ESTATES CA
90274-7612
US

IV. Provider business mailing address

1034 W.14TH STREET
SAN PEDRO CA
90731
US

V. Phone/Fax

Practice location:
  • Phone: 213-485-3300
  • Fax:
Mailing address:
  • Phone: 213-485-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY17723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: