Provider Demographics
NPI:1457613481
Name:MARISCAL, BERNADETTE (MA, LAC, NCC)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:MARISCAL
Suffix:
Gender:F
Credentials:MA, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 E HUNT HWY
Mailing Address - Street 2:SUITE 16, PBM # 144
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4962
Mailing Address - Country:US
Mailing Address - Phone:602-326-5379
Mailing Address - Fax:
Practice Address - Street 1:5418 E SKYLINE DR
Practice Address - Street 2:BUILDING 1
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-9000
Practice Address - Country:US
Practice Address - Phone:602-326-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-13757101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health