Provider Demographics
NPI:1750756425
Name:NERSISYAN, MARINE
Entity type:Individual
Prefix:
First Name:MARINE
Middle Name:
Last Name:NERSISYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARINE
Other - Middle Name:
Other - Last Name:AYDINDZHYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 S SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3536
Mailing Address - Country:US
Mailing Address - Phone:626-254-5000
Mailing Address - Fax:626-294-1077
Practice Address - Street 1:237 N CENTRAL AVE
Practice Address - Street 2:SUITE 235
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2531
Practice Address - Country:US
Practice Address - Phone:818-547-9544
Practice Address - Fax:818-549-9041
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99420106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist