=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710776323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARILISA RAJU, PHD PSYCHOLOGIST, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2025
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2447 PACIFIC COAST HWY STE 200
-----------------------------------------------------
City | HERMOSA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90254-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-206-5219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12625 FREDERICK STREET ST #I5-150
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-206-5219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MARILISA RAJU
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 909-206-5219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------