Provider Demographics
NPI:1003534900
Name:ANDERSEN, MARI KONOSHIMA
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:KONOSHIMA
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 LA MIRADA ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3570
Mailing Address - Country:US
Mailing Address - Phone:949-228-1662
Mailing Address - Fax:
Practice Address - Street 1:3551 CAMINO MIRA COSTA STE T
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3508
Practice Address - Country:US
Practice Address - Phone:949-272-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132206106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist