Provider Demographics
NPI:1689131682
Name:RAJU, MARILISA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARILISA
Middle Name:
Last Name:RAJU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 FREDERICK ST
Mailing Address - Street 2:# I5-150
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12625 FREDERICK STREET
Practice Address - Street 2:#I5-150
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5216
Practice Address - Country:US
Practice Address - Phone:909-206-5219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL