Basic Information
Provider Information | |||||||||
NPI: | 1255580676 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZURIC | ||||||||
FirstName: | MARCIA | ||||||||
MiddleName: | DEESHAI | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | RAS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ELLIS | ||||||||
OtherFirstName: | MARCIA | ||||||||
OtherMiddleName: | DEESHAI | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 717 LINCOLN BLVD | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | CA | ||||||||
PostalCode: | 90291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103999883 | ||||||||
FaxNumber: | 3103999678 | ||||||||
Practice Location | |||||||||
Address1: | 637 E ALBERTONI ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | CARSON | ||||||||
State: | CA | ||||||||
PostalCode: | 907461543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3102170616 | ||||||||
FaxNumber: | 3102170545 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2008 | ||||||||
LastUpdateDate: | 07/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 197247 | 05 | CA |   | MEDICAID |