Provider Demographics
NPI:1740931351
Name:PROIETTA, MARYKATHERINE
Entity type:Individual
Prefix:
First Name:MARYKATHERINE
Middle Name:
Last Name:PROIETTA
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 1:12443 CULVER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6612
Mailing Address - Country:US
Mailing Address - Phone:315-559-0401
Mailing Address - Fax:
Practice Address - Street 1:2512 ARTESIA BLVD STE 305C
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3269
Practice Address - Country:US
Practice Address - Phone:424-261-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1031791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty