Healthcare Provider Details

I. General information

NPI: 1558040733
Provider Name (Legal Business Name): MARISSA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 ANGELES VISTA BLVD
VIEW PARK CA
90043-1101
US

IV. Provider business mailing address

4419 ANGELES VISTA BLVD
VIEW PARK CA
90043-1101
US

V. Phone/Fax

Practice location:
  • Phone: 310-259-0493
  • Fax:
Mailing address:
  • Phone: 310-259-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119939
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: