Provider Demographics
NPI:1013095629
Name:BARROS-NISKA, MARYLOUISE NONE (MFCC AND PHD)
Entity Type:Individual
Prefix:DR
First Name:MARYLOUISE
Middle Name:NONE
Last Name:BARROS-NISKA
Suffix:
Gender:F
Credentials:MFCC AND PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 W.14TH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731
Mailing Address - Country:US
Mailing Address - Phone:213-485-3300
Mailing Address - Fax:
Practice Address - Street 1:707 SILVER SPUR RD
Practice Address - Street 2:STE 101
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-7612
Practice Address - Country:US
Practice Address - Phone:213-485-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17723103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103TC0700XMedicare ID - Type UnspecifiedPH.D