Provider Demographics
NPI:1609339530
Name:GERVACIO, MARIEL
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:GERVACIO
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 1:7443 FOUR WINDS CT
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3025
Mailing Address - Country:US
Mailing Address - Phone:951-737-7202
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:909-620-9793
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105302106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist