Provider Demographics
NPI:1972039071
Name:HUGHES, MARISA (LEP)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:HUGHES
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 WOODRUFF AVE
Mailing Address - Street 2:#35
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1534
Mailing Address - Country:US
Mailing Address - Phone:657-464-5188
Mailing Address - Fax:
Practice Address - Street 1:3711 N HARBOR BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-1362
Practice Address - Country:US
Practice Address - Phone:657-464-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3486103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool