Provider Demographics
NPI:1700151206
Name:ALDAZ, MARISOL (MS)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:ALDAZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3436
Mailing Address - Country:US
Mailing Address - Phone:909-890-5930
Mailing Address - Fax:909-890-5950
Practice Address - Street 1:1908 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-890-5930
Practice Address - Fax:909-890-5930
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA108253106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist