Provider Demographics
NPI:1518411552
Name:BRUNNETT-LAZARTE, MARIANA (LMFT)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:BRUNNETT-LAZARTE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MARIANA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2911 ADAMS AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1509
Mailing Address - Country:US
Mailing Address - Phone:760-717-0617
Mailing Address - Fax:855-932-2055
Practice Address - Street 1:1161 BAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2670
Practice Address - Country:US
Practice Address - Phone:619-585-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111158106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist