Provider Demographics
NPI:1093273849
Name:DEARBORN, MARISSA DANIELLE (AMFT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:DANIELLE
Last Name:DEARBORN
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 FLYNN RD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8741
Mailing Address - Country:US
Mailing Address - Phone:805-334-5195
Mailing Address - Fax:
Practice Address - Street 1:1100 FLYNN RD UNIT 201
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8741
Practice Address - Country:US
Practice Address - Phone:805-334-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108469101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE