Healthcare Provider Details

I. General information

NPI: 1528737889
Provider Name (Legal Business Name): MARLON VINCENTE GAMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701
US

IV. Provider business mailing address

14524 CORTINA DR
LA MIRADA CA
90638
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 562-447-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number143941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: