Healthcare Provider Details

I. General information

NPI: 1538449194
Provider Name (Legal Business Name): MARCO ARMANDO HIDALGO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 16TH ST STE 125
SANTA MONICA CA
90404-1240
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90095-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-8900
  • Fax: 310-315-8902
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008597
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPSY29794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: