Provider Demographics
NPI:1609277136
Name:JUSTICE, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S LA FAYETTE PARK PL APT 507
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-5419
Mailing Address - Country:US
Mailing Address - Phone:740-463-9085
Mailing Address - Fax:
Practice Address - Street 1:500 N FLOWER ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-2361
Practice Address - Country:US
Practice Address - Phone:714-647-4672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic