Provider Demographics
NPI:1275168924
Name:DICK, MARISA SARA-NICHELLE
Entity Type:Individual
Prefix:MISS
First Name:MARISA
Middle Name:SARA-NICHELLE
Last Name:DICK
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 1:21600 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:6939 SUNRISE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-3153
Practice Address - Country:US
Practice Address - Phone:916-547-5908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician