Healthcare Provider Details

I. General information

NPI: 1124490446
Provider Name (Legal Business Name): VICTORVILLE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15431 ANACAPA RD SUITE # D
VICTORVILLE CA
92392
US

IV. Provider business mailing address

15431 ANACAPA RD SUITE # D
VICTORVILLE CA
92392
US

V. Phone/Fax

Practice location:
  • Phone: 951-333-7363
  • Fax: 760-240-3728
Mailing address:
  • Phone: 951-333-7363
  • Fax: 760-240-3728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMFC # 53104
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberMFC # 53104
License Number StateCA

VIII. Authorized Official

Name: DR. MAYADA MARZOUK
Title or Position: CLINICIAN
Credential: LMFT
Phone: 951-333-7363