Healthcare Provider Details

I. General information

NPI: 1245158807
Provider Name (Legal Business Name): MARIEL RENEE TIVOLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12626 RIVERSIDE DR STE 409
VALLEY VILLAGE CA
91607-3451
US

IV. Provider business mailing address

2323 S BEVERLY GLEN BLVD UNIT 2
LOS ANGELES CA
90064-2591
US

V. Phone/Fax

Practice location:
  • Phone: 818-661-6306
  • Fax:
Mailing address:
  • Phone: 310-889-8953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC22660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: