Provider Demographics
NPI:1568593101
Name:CORDERO, MARISSA ANNE (MA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:CORDERO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11738 MAGNOLIA BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-5604
Mailing Address - Country:US
Mailing Address - Phone:818-645-3659
Mailing Address - Fax:
Practice Address - Street 1:12450 VAN NUYS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1391
Practice Address - Country:US
Practice Address - Phone:818-896-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF47546225400000X
CAMFC 47090106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner