MEDICARE: PACIFICA NEUROPSYCHOLOGY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC 42200	CA
2	103G00000X	Clinical Neuropsychologist	PSY 19781	CA

General Provider Information

NPI Number	:	1962783951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFICA NEUROPSYCHOLOGY CENTER

Provider Business Mailing Address
First Line	:	461 W 6TH ST, SUITE 211
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2694
Country	:	US
Telephone Number	:	310-547-0084
Fax Number	:	310-833-5672

Provider Business Practice Location Address
First Line	:	461 W 6TH ST, SUITE 211
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2694
Country	:	US
Telephone Number	:	310-547-0084
Fax Number	:	310-833-5672

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MARISA MARES
Credential	:	PH.D
Telephone Number	:	310-547-0084

Provider Enumeration Date	:	09/02/2011
Last Update Date	:	01/26/2017

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