Provider Demographics
NPI:1801011531
Name:KAKISHIMA, MARLI
Entity Type:Individual
Prefix:
First Name:MARLI
Middle Name:
Last Name:KAKISHIMA
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 1:18757 BURBANK BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-345-8355
Mailing Address - Fax:818-345-8755
Practice Address - Street 1:22713 S. VERMONT AVE.
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90500
Practice Address - Country:US
Practice Address - Phone:310-320-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7484Medicaid