Provider Demographics
NPI:1659094951
Name:ANCHONDO, MARISA MARIE (MS)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:MARIE
Last Name:ANCHONDO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14460 DEL AMO DR
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-5493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6809 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4221
Practice Address - Country:US
Practice Address - Phone:951-774-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician