Healthcare Provider Details

I. General information

NPI: 1689395683
Provider Name (Legal Business Name): EVERARDO MARIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W 1ST ST
TUSTIN CA
92780-2950
US

IV. Provider business mailing address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-9890
  • Fax:
Mailing address:
  • Phone: 714-665-9890
  • Fax: 714-665-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW130929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: