Healthcare Provider Details

I. General information

NPI: 1417308784
Provider Name (Legal Business Name): MARYLY GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 E DYER RD SUITE 120
SANTA ANA CA
92705-5600
US

IV. Provider business mailing address

1221 E DYER RD SUITE 120
SANTA ANA CA
92705-5600
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-0488
  • Fax:
Mailing address:
  • Phone: 949-250-0488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1528245909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: