Provider Demographics
NPI:1215376884
Name:ROCHA, MARIO ANGEL
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ANGEL
Last Name:ROCHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 E COOLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3905
Mailing Address - Country:US
Mailing Address - Phone:909-580-3705
Mailing Address - Fax:
Practice Address - Street 1:237 W MILL ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-1403
Practice Address - Country:US
Practice Address - Phone:909-388-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF81727106H00000X
CALMFT110095106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist