Provider Demographics
NPI:1487210613
Name:DE ARCOS, MARISOL TRUJILLO I
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:TRUJILLO
Last Name:DE ARCOS
Suffix:I
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARISOL
Other - Middle Name:TRUJILLO
Other - Last Name:DE ARCOS
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 PADRE PKWY. STE. 101
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2332
Mailing Address - Country:US
Mailing Address - Phone:510-571-9433
Mailing Address - Fax:
Practice Address - Street 1:2 PADRE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2114
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician