Provider Demographics
NPI:1265940373
Name:RONQUILLO, MARISA (LMFT)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:RONQUILLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 CLARKSVILLE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-8210
Mailing Address - Country:US
Mailing Address - Phone:916-983-8868
Mailing Address - Fax:
Practice Address - Street 1:82 CLARKSVILLE RD STE 120
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-8210
Practice Address - Country:US
Practice Address - Phone:916-983-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA122594106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health