Provider Demographics
NPI:1780718890
Name:POBLANO, MARLISA (MFT)
Entity type:Individual
Prefix:MS
First Name:MARLISA
Middle Name:
Last Name:POBLANO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 S CALIFORNIA AVE #2631
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91793-3522
Mailing Address - Country:US
Mailing Address - Phone:626-430-2999
Mailing Address - Fax:
Practice Address - Street 1:1359 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1016
Practice Address - Country:US
Practice Address - Phone:266-430-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46805106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAENK1404OtherL.A. DEPT. MENTAL HEALTH