Provider Demographics
NPI:1598492035
Name:MIARA, MARISSA (APCC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MIARA
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 LINCOLN BLVD APT 127
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-9310
Mailing Address - Country:US
Mailing Address - Phone:845-826-5686
Mailing Address - Fax:
Practice Address - Street 1:11600 WASHINGTON PL STE 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5068
Practice Address - Country:US
Practice Address - Phone:323-329-6798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC12059101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health