Provider Demographics
NPI:1922386135
Name:HUERTA, MARISELA (PHD)
Entity Type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:HUERTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 YORK AVE
Mailing Address - Street 2:APT. 2M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7940
Mailing Address - Country:US
Mailing Address - Phone:773-936-9777
Mailing Address - Fax:
Practice Address - Street 1:21 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1504
Practice Address - Country:US
Practice Address - Phone:914-997-5947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014769103TC0700X
NY68019264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical