Provider Demographics
NPI:1750665915
Name:ELPIDAMA, MARISSA GARCIA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:GARCIA
Last Name:ELPIDAMA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARISSA
Other - Middle Name:JUAN
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 941834
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93094-1834
Mailing Address - Country:US
Mailing Address - Phone:805-918-4819
Mailing Address - Fax:805-583-9934
Practice Address - Street 1:1720 E LOS ANGELES AVE STE 221
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-5854
Practice Address - Country:US
Practice Address - Phone:805-501-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24487103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist