Provider Demographics
NPI:1558775783
Name:MARAVILLA, TRICIA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:MARAVILLA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 E ROSINA ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-4463
Mailing Address - Country:US
Mailing Address - Phone:562-882-1831
Mailing Address - Fax:
Practice Address - Street 1:18700 BEACH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2089
Practice Address - Country:US
Practice Address - Phone:714-962-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15849235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist