Provider Demographics
NPI:1770787624
Name:THROCKMORTON, MARCELA A (MFT)
Entity type:Individual
Prefix:
First Name:MARCELA
Middle Name:A
Last Name:THROCKMORTON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:MARCELA
Other - Middle Name:A
Other - Last Name:THROCKMORTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:3151 AIRWAY AVE
Mailing Address - Street 2:SUITE T-2
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4607
Mailing Address - Country:US
Mailing Address - Phone:949-466-0669
Mailing Address - Fax:
Practice Address - Street 1:17542 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3155
Practice Address - Country:US
Practice Address - Phone:949-466-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43269106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist