Provider Demographics
NPI:1003434986
Name:ELIAS-JUAREZ, MARCO ANTONIO
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:ANTONIO
Last Name:ELIAS-JUAREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARCO
Other - Middle Name:ANTONIO
Other - Last Name:ELIAS-JUAREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MARCO ELIAS
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-5022
Mailing Address - Fax:
Practice Address - Street 1:3125 MYERS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5527
Practice Address - Country:US
Practice Address - Phone:951-486-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT83864106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist