Provider Demographics
NPI:1003623034
Name:ROBERTO, MARA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:ROBERTO
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 1:1382 BLUE OAKS BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-7052
Mailing Address - Country:US
Mailing Address - Phone:619-900-0599
Mailing Address - Fax:
Practice Address - Street 1:9611 PETITE LN
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-4317
Practice Address - Country:US
Practice Address - Phone:619-390-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147412106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist