Provider Demographics
NPI:1780009803
Name:ICE, MARISA (MA, LMFT)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:ICE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2919
Mailing Address - Country:US
Mailing Address - Phone:323-677-1963
Mailing Address - Fax:
Practice Address - Street 1:840 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2919
Practice Address - Country:US
Practice Address - Phone:323-677-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53913106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist