Provider Demographics
NPI:1033653100
Name:CHERRY, MARISA JILL
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:JILL
Last Name:CHERRY
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 1:16027 BROOKHURST ST STE I-2006
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1551
Mailing Address - Country:US
Mailing Address - Phone:949-436-5023
Mailing Address - Fax:
Practice Address - Street 1:16027 BROOKHURST ST # I-2006
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1551
Practice Address - Country:US
Practice Address - Phone:949-436-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW826651041C0700X
CA949721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical