Provider Demographics
NPI:1033203054
Name:MARES, MARISA (PHD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MARES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 W 6TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2694
Mailing Address - Country:US
Mailing Address - Phone:310-547-0084
Mailing Address - Fax:310-833-5672
Practice Address - Street 1:461 W 6TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2694
Practice Address - Country:US
Practice Address - Phone:310-547-0084
Practice Address - Fax:310-833-5672
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19781103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP19781BMedicare ID - Type Unspecified
CAWCP19781AMedicare ID - Type Unspecified