Provider Demographics
NPI:1477365658
Name:MARISCAL, MARIELLENA
Entity type:Individual
Prefix:
First Name:MARIELLENA
Middle Name:
Last Name:MARISCAL
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 1:2977 GUNNERY FORGE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-3784
Mailing Address - Country:US
Mailing Address - Phone:760-829-8183
Mailing Address - Fax:
Practice Address - Street 1:2977 GUNNERY FORGE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-3784
Practice Address - Country:US
Practice Address - Phone:760-829-8183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-25-406072106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician