Provider Demographics
NPI:1659497204
Name:GARDUNO, MARISOL (LCSW)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:GARDUNO
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 1:1200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1908
Mailing Address - Country:US
Mailing Address - Phone:213-481-7464
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1932
Practice Address - Country:US
Practice Address - Phone:213-482-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW30122101YM0800X
CAASW17983101YM0800X
CALCSW647481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health