Healthcare Provider Details

I. General information

NPI: 1619680352
Provider Name (Legal Business Name): JOANNA IRIS-BRADBURY MARQUIS LMFT 153515
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOANNA VARGAS

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1563 MISSION ST
SAN FRANCISCO CA
94103-2543
US

IV. Provider business mailing address

440 N BARRANCA AVE # 2990
COVINA CA
91723-1722
US

V. Phone/Fax

Practice location:
  • Phone: 415-940-2542
  • Fax:
Mailing address:
  • Phone: 415-762-3700
  • Fax: 415-865-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12013
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12013
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number153515
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: