Provider Demographics
NPI:1679261952
Name:ANTILLA, MARISSA YVETTE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:YVETTE
Last Name:ANTILLA
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 1:1563 SYCAMORE CT
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-1468
Mailing Address - Country:US
Mailing Address - Phone:951-524-8410
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:760-992-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician