Healthcare Provider Details

I. General information

NPI: 1417593674
Provider Name (Legal Business Name): MARISOL BALDERAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 12/06/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CABRILLO PARK DR
SANTA ANA CA
92701-5017
US

IV. Provider business mailing address

525 CABRILLO PARK DR
SANTA ANA CA
92701-5017
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • 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 StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: