Provider Demographics
NPI:1619745056
Name:SALIM, MARENDRA B
Entity Type:Individual
Prefix:MR
First Name:MARENDRA
Middle Name:B
Last Name:SALIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24411 NAN CT
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4380
Mailing Address - Country:US
Mailing Address - Phone:909-954-1200
Mailing Address - Fax:
Practice Address - Street 1:9570 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5842
Practice Address - Country:US
Practice Address - Phone:909-980-4755
Practice Address - Fax:909-790-2148
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC10452101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health