Healthcare Provider Details

I. General information

NPI: 1962783951
Provider Name (Legal Business Name): PACIFICA NEUROPSYCHOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 W 6TH ST, SUITE 211
SAN PEDRO CA
90731-2694
US

IV. Provider business mailing address

461 W 6TH ST, SUITE 211
SAN PEDRO CA
90731-2694
US

V. Phone/Fax

Practice location:
  • Phone: 310-547-0084
  • Fax: 310-833-5672
Mailing address:
  • Phone: 310-547-0084
  • Fax: 310-833-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 19781
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 42200
License Number StateCA

VIII. Authorized Official

Name: MARISA MARES
Title or Position: CLINICAL DIRECTOR
Credential: PH.D
Phone: 310-547-0084