Provider Demographics
NPI:1053058909
Name:LATORRE DEWEESE, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:LATORRE DEWEESE
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 1:1522 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-6156
Mailing Address - Country:US
Mailing Address - Phone:714-616-6634
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:213-842-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4231871Medicaid
CAE4231871OtherMEDICAL