Provider Demographics
NPI:1649764754
Name:FORTUNA, MARI ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARI ANN
Middle Name:
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 WILSHIRE BLVD STE 504
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3717
Mailing Address - Country:US
Mailing Address - Phone:323-960-0321
Mailing Address - Fax:
Practice Address - Street 1:4311 WILSHIRE BLVD STE 504
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3717
Practice Address - Country:US
Practice Address - Phone:323-960-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA188291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical